Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 3 Nov 1992

Vol. 424 No. 8

Private Members' Business. - General Medical Service: Motion.

I move:

That Dáil Éireann, conscious of the enormous worry being caused to 1.2 million people in the General Medical Service Scheme particularly to the elderly and the very young, by the possible withdrawal of a majority of general practitiners from the Scheme:—

—condemns the Minister for Health for his unwillingness to enter into meaningful discussions with the Irish Medical Organisation on a review of the Scheme;

—calls on the Minister to take steps to remove the threat of the collapse of the Scheme; and

—calls on the Minister to recognise the need for major investment in the Scheme, so that the quality of the service delivered is kept up to the highest standard.

I wish to share my time with Deputies Allen and Belton.

Is that satisfactory? Agreed.

I very much regret that this motion would appear to be the last Private Members' motion in this Government's term of office. The issues are of grave importance nationally to over one million people. It is a disgrace that the country is caught up in the instability caused by the Government rather than the issues which really affect the lives of people.

Fine Gael have tabled this motion to highlight to the Minister and the Dáil the serious crisis pending in the health services if the GPs operating the GMS scheme go ahead with their resignations from the scheme, operative from 8 December this year. There are approximately 700,000 medical card holders, representing over 1.2 million individuals, all of whom are threatened by a loss of a health service if the Minister for Health cannot assure us that he is involved in realistic and meaningful discussions with the Irish Medical Organisation and the ICGP.

The action being proposed by over 1,000 doctors in resigning from their contracts with the GMS is unprecedented. Why is it that general practitioners, who by the very nature of their profession are caring and responsible for the lives and health of people, are considering withdrawing their services from the most vulnerable sector in society, the GMS patients? GPs are one of the least likely groups to take such action unless they feel there is literally no other course of action which will highlight the seriousness of the problem within the GMS scheme.

Individual doctors have expressed anger that the Minister and the Government feel they can play them along on the assumption that doctors will not turn away patients who require treatment. This of course, is true. GPs have clearly stated that no patient in need of acute and emergency treatment will be turned away without care. They have also made it clear that medical card patients will be seen, but in a non-emergency situation the options for these patients will be either to pay the doctor and seek reimbursement from their local health board or to seek approval from the health board first and the necessary money to pay the doctor before the visit. Doctors who have threatened to resign their contracts will no longer be able after 8 December to issue GMS prescriptions and therefore private prescriptions will have to be taken to local pharmacists for dispensing and payment. Medical card holders will either have to pay for the prescriptions, many of them extremely expensive, and seek reimbursement or have their prescriptions filled at health board clinics. Alternatively they could seek the money from the health board first before getting the prescriptions filled.

From my discussions with various sectors of the IMO and the ICGP and individual GPs, I warn the Minister that the doctors concerned are deadly serious in their intention to have improvements made in the GMS system, so that patients under their care can receive the same quality of service that private patients can pay for. The ICGP have clearly indicated that rather than continue to participate with departmental cost-cutting exercises resulting in falling standards of care, Irish GPs have voted to withdraw from what is becoming in their view a shoddy, discriminatory system for the less well off members of society.

This is not a case of an élite section of society looking for a huge increase in their personal income. I am sure the Minister recognises that this is the same group of medical practitioners who are loudly proclaiming that the investment required to provide a decent quality service to the least well off has not been forthcoming, as promised by the Minister's Government in 1989 when the old system was replaced by the capitation system of payment. The annual budget of the Department of Health is approximately £1.7 billion. Despite the huge number of our population dependent on the GMS for healthcare, only about 10 per cent of the total budget is spent on the GMS. I recognise the very high cost of drugs but there are a number of ways that could be tackled. The Minister has failed to do so.

Lest the Minister make a big issue of the amount of money being spent on healthcare, there is a trend throughout Europe and elsewhere to spend more and more of the government budget on healthcare. This is a recognition by Governments that society should be able to provide a decent and adequate quality service for their people's health. A healthy population will be more productive, more efficient, less depressed, less crime ridden, more caring, particularly of their young and their elderly, and of course more long lived.

I want to look at how the public health system we have now evolved. As I said at the beginning, prior to 1972 health services, medicines, etc., for certain income classes were provided through the old dispensary system. This was, as one doctor put it to me, a "much hated system" which created divisions in our society of the poor versus the rich. This is not to say that the doctors involved in the old dispensary system were not striving to provide the best possible care and attention for their patients but the structure of the system was inadequate, under-resourced and, of necessity, neither value for money nor providing the kind of quality service which our people have the right to expect.

The transition in 1972 to the "choice of doctor scheme", whereby people on medical cards could opt for a doctor of their choice, living in their own locality, brought a dignity and an equality into the provision of health care. No longer would people, through unemployment, low income, etc., be so readily identified and separated from their neighbours. With the introduction of the "choice of doctor scheme", patients sitting in a doctor's waiting room would be entitled to and receive equal care, irrespective of whether they were personally paying the bill or not. No one doubts the progressiveness of this move and any attempt to revert to the old system of segregation, as allegedly threatened by the Minister and his Department in this current debate, would be dreadfully regressive and would be fought tooth and nail by the medical practitioners and more importantly by the patients in the GMS scheme, who would be the losers.

In 1972 the GPs were divided on the principle of fee-per-item or a capitation scheme, which would involve a single payment per annum for each patient on their list. In the end, the system introduced involved a fee per item with a rejection at the time of a capitation system, part of which was specifically related to "out of hours" availability, special fees for night visits, emergency treatment and special services. Some GPs now argue that it was this rejection of the capitation system at that stage that was the start of their current problems. However, be that as it may, the fee-per-item system operated until 1989, when following intensive negotiations, the capitation scheme was introduced with a built-in three year review.

With the introduction in 1989 of the capitation scheme, doctors would now be eligible for a proportionate pension upon retirement based on their payments into the pension scheme, they would be entitled to special grants to upgrade their practices, payments towards provision of nurse and/or secretary, study leave and locum payments for holiday leave and most importantly, there was a commitment on the part of Government for investment in the GMS scheme generally.

Before the acceptance of this capitation system, the doctors were assured that their incomes would not drop as a result of its introduction. However, let us look at the actual facts since 1989, as outlined by the IMO: there has been an average 25 per cent reduction in gross income for doctors with no change in list sizes; as in fact, in 1992 evidence is there that there will be a drop of 40 per cent in income since 1983; and of the £45 average payment received for a particular category of patient, a doctor will receive only £21 per annum before tax. The 27 per cent withholding tax, which the doctors accept they must pay like anybody else, is deducted from all payments to doctors before those payments are made and this has the effect that doctors are paying, first of all, tax on part of the repayments which are not eligible for tax and which they have to claim back and, second, that they are paying their tax in some instances three years ahead of the eligible year.

I would like to read the Minister a letter I received from the wife of a general practitioner in the southern part of the country:

In theory the retention tax may sound feasible, but in practice it is utterly unjust. The continuous deductions are actually payments, or in our case, overpayments of income tax by monthly instalments of up to three years in advance.

The Government has this continuous interest free loan from the GP which will not be repaid until the GP retires.

The cost of this to the GP is high. It results in the business having a continuous overdraft. Large expenses like medical defence insurance and accountants fees are paid by bank loans. All expenses are paid "up front" by the GP while any grants or subsidies paid by the Department of Health are paid in arrears and minus retention tax.

In summary, as a result of the retention tax, GPs are taxed up to three years in advance. Their working capital has to be funded by bank loans and overdrafts. They provide a wonderful service but the frustration they feel as a result of this injustice is forcing them to strike action.

That is from the wife of a general practitioner who has personal knowledge and experience of how the system is operating for them and the difficulties it is causing for them.

Since the 1989 scheme no real investment has been made available for improvements of practices. Payments for nurses and secretaries are made quarterly, which means that many doctors have to raise loans and fund such loans in order to pay their staff. They cannot ask their staff to wait three months until they get their payments. This has put huge pressure on many doctors, forcing some to get rid of staff or avoid hiring staff and use the unpaid services of their own spouses or offspring to assist in the practice.

The system for applying for study leave has also been criticised. It is so complicated and so slow that many doctors find it impossible to avail of this and, if they do, all the payments take so long that the doctors have "out-of-pocket" expenses. Again, any payments are subject to 27 per cent withholding tax before the payment is made despite the fact that expenses are not eligible for withholding tax.

The amount of money paid for locum cover for holiday leave is such that it costs doctor money to take annual leave. At Question Time recently the Minister said that the holiday fund had not all been taken up. The reason is that it costs a doctor to take holidays and pay a locum, the Minister probably knows that from his own experience in general practice.

In February 1992, when the Minister was appointed as Minister for Health, he sought a meeting with the IMO as he had heard of the dissatisfaction of the GPs and their support for some kind of withdrawal from the GMS. The IMO gave that hearing to the Minister based on a willingness to hear out a new appointee and, more important, on the understanding that here was a fellow medical practitioner who they felt would have a deeper understanding of the difficulties they were suffering. At that meeting the Minister urged the doctors not to take the action they were proposing, not to sign withdrawal from their contracts until he had had a chance to commence the three year review of the 1989 capitation system and also the examine the possibility of the payment of an arbitration award of 17.5 per cent to the doctors irrespective of the three year review. If the doctors agreed——

That is wrong.

The Minister will have a chance to correct me there, but that is the doctors' understanding and I have articles here in the doctors' newspapers indicating that. An arbitrator agreed that they should have an increase in payments irrespecive of the three year review but again it was decided to leave that over while the review as going on. The doctors agreed to give the Minister the time he sought but I know now from my own discussions that there is deep anger out there that they were misled by the Minister. All that has happened in the intervening time is that they have done without their arbitration award.

The Deputy has said that I misled them. That is a very serious allegation.

I said that the doctors have alleged it to me. I am entitled to pass on the opinion that was put to me.

The Deputy is entitled to her opinion.

We really have got into a situation now where one has to be so sensitive to every word that there is no "C" word any longer, there is no "D" word and now I cannot use the "M" word, "mislead". Does the Minister want me to use the "L" word, perhaps?

It is an allegation and the Minister will have his opportunity of replying shortly.

The doctors have alleged to me that they feel misled by the Minister and that all that has happened in the intervening time is that they have done without their arbitration award and that they have been let down by a fellow professional and by the Department of Health. I am sure the Minister is still on the mailing list for the Irish Medical Times and the Irish Medical News and I am sure he sees that anger being voiced in articles week after week. I want to stress most that in all these arguments and counter-arguments, the most important individual is the patient. The GMS patients is entitled to a medical card by virue of a low income which makes him or her eligible for such a medical card. Because of that he or she is more likely to be at risk from illnesses associated with low incomes, poor housing, old age. They are at risk from such things as depression, conditions resulting from poor nutrition perhaps alcoholism, colds, bronchitis, respiratory problems often associated with poor and damp housing conditions; and we know that over the last five years those poor and damp housing conditions have increased for very many of our medical card holders.

A high percentage of GMS patients will also be single parents with the associated pressures on, particularly, young mothers with poor back-up service and, very often, no family support. Urban doctors have indicated to me that there is a huge increase in the number of visits and surgery calls being received, particularly from this latter section of medical card holders. A young mother under 20 living in single room accommodation with a small baby will very often pay three or four visits a week to a doctor or make three or four calls to the doctor to visit her at home because of fear, very often, and lack of experience in minding a small baby. Very often the local GP is the only back-up care service that she can call upon if her baby is perpetually crying or staying awake or generally unwell. Very often the GP has to intervene to ensure that the baby is treated properly and is not maltreated because of pressure on the mother.

Irrespective of the number of times the doctor will attend such a patient, the payment per annum is extremely disproportionate to the commitment involved on the part of the doctor. I know the Minister will have been one of those doctors who was totally committed to his patient but we cannot abuse that caring nature.

In conclusion, before handing over to some of my colleagues, I want to say that the full responsibility rests on the Minister's shoulders to sort out his problem with the doctors. Regardless of whether this Government fall in the next few days the Minister cannot shirk that responsibility because he will still be the Minister during the interregnum. I urge the Minister to realistically discuss with the IMO what his proposals are to improve the GMS with the prime objective of ensuring that the service is patient friendly, efficient, value for money and delivering the highest possible quality of service. If we can get the service doing all that, then both the patients and the doctors will be satisfied.

The Minister should never forget, and I am sure he does not, that without the service of more than 1,500 doctors in this country we could not provide a health service to the 1.2 million people who depend on the public health system. I equally use this debate to call on the doctors' representatives to have a full and clear understanding of the difficulties in this country and the need for them also to have realistic and attainable objectives. With such openness in the debate and discussions a solution can be found to the problems facing doctors and patients under the GMS.

If the GMS system collapses from 8 December next there will be chaos with regard to the provision of public health services. I appeal to the Minister not to introduce any interim scheme under which young hospital doctors or doctors who are out of work would be employed which would lead to allegations such as "IMO to get tough on scab GMS doctors" being made in the medical services.

Many thousands of people fear that they will not receive medical treatment when they need it. Doctos have been forced to indicate to repeat prescription holders that they will not be given a repeat prescription from mid-November as they will be invalid if doctors resign from the scheme. The other day a person with a serious heart condition and asthma telephoned me to say that she needed about £120 worth of drugs each month and does not know what she will do when she has to renew her prescription in mid-November if the doctors withdraw from the GMS scheme.

I would like the Minister to tell us tonight during this debate what these people should do. He must have contingency plans if he does not think he will be able to resolve the problems confronting him. He must surely realise that if the GMS system collapses the emergency services in hospitals will come under pressure. Given the additional costs that will be incurred and the difficulties confronting the hospitals already due to the reduction in the number of beds and long waiting lists, the Minister will save nothing if he allows the system to collapse. As he is aware, the hospital doctors have indicated already that they will not be able to cater for medical card holders if they pour into the accident and emergency departments of hospitals in their hundreds.

I put it to the Minister that it would be far better if he recognised the legitimate case for more investment in the GMS system not because this is what the doctors are asking for but because it is required if we are to meet the needs of patients and to ensure that we do not return to a situation where it is a question of rich versus poor in the delivery of health services.

Already in this House today, and rightly so, the appalling plight of the people of Somalia and other trouble spots in the world have been highlighted but in endeavouring to meet our responsibilities worldwide we sometimes tend to forget about the people on our own doorstep. At a time of tribunals, Government crises and other international events it seems to have been forgotten that a problem is festering which will affect many thousands of underprivileged people. We have a forgotten people and a hidden Ireland and during the next few weeks thousands of medical card holders and their dependants will become more anxious and fearful in relation to the impasse between the Minister, his Department and the IMO.

Much lip-service has been paid to the community care service down through the years by successive Ministers and it remains the Cinderella of the health services. Over 50 per cent or £700 million of the annual budget is allocated to the hospital services but these services are inefficient. In addition there are long waiting lists and widespread abuses about which the Minister has spoken, yet done very little about them. On the other hand, the community care service is highly efficient. Since 1989 1,578 doctors have been employed on contracts at a cost of £56 million per annum to work from 8 a.m. to 10 p.m. seven days a week. Indeed, if they are unavailable they have to provide a substitute. This is a cheap service and it is underdeveloped and underfunded. The Minister has a responsibility to look after these doctors.

Very few complaints have been received under the GMS during the past 20 years. While we have received many complaints about the quality of the service provided in our hospitals only rarely do we receive a complaint about a general practitioner who has been negligent. I submit that the general practitioners have been the unsung heroes of the medical services for far too long and have been taken for granted. I believe that they are right not to take it lying down and have a right to receive a fair salary for the service they are providing.

Since the capitation system was introduced the income of general practitioners has dropped. Statistics show that £56 million is paid to general practitioners each year while £100 million is paid out on drugs alone. I put it to the Minister that instead of screwing the general practitioners to the wall he should attempt to reach a compromise with the FICI. Even though the cost of drugs is escalating, once the National Drugs Advisory Board approve of a drug it can be prescribed immediately under the GMS, irrespective of the cost involved. It would be far better if the Minister came to grips with the problem of escalating drug costs rather than to try to pin down the level of income for general practitioners who have been to the forefront of the medical services down through the decades.

It is more than likely that an election will be held during the next few weeks and amid all the excitement, hype and competition between the political parties there are people who feel aggrieved, who feel they have been forgotten and that they have been let down by the Government. Many a word will be spoken about this matter in the heat of an election campaign but at the end of the day it is in the Minister's hands. I hope that tonight the Minister will send a signal of hope to those people.

The IMO now realise that they were ill-advised to advise their members to agree to the present system. In realising their mistake I hope the leadership of the IMO will enter into realistic negotiations with the Minister. In recent days I have spoken to a number of general practitioners. Indeed, this matter was debated at the meeting of the Southern Health Board yesterday when concern was expressed by all members.

It is clear that there will be chaos in the weeks ahead. In her contribution Deputy Owen outlined the position in detail and it is up to the Minister to try to reach a settlement. I hope that before this debate concludes tomorrow night he will bring forward realistic proposals to resolve this dispute. Even as we speak secretaries and assistants in general practitioner practices around the country, about 1,000 in all, are being served with protective notice. This marks the beginning of the process of winding down the service. As I said at the outset, this will affect the most vulnerable, the elderly and the sick, in our community. Despite the political crisis we have a responsibility to look after these people.

I welcome the opportunity to speak on this matter tonight. I do not have to give the Minister much detail on health matters but very often the responsibility of being a member of the Government outweighs that of other immediate considerations. General practitioners carry out necessary work and provide employment in areas where jobs are very scarce. They are in the front line of medical care. Unfortunately, in many cases these people are seldom appreciated until they are no longer there. There is no doubt that down the years general practitioners have, to a certain extent, been taken for granted by the public and the Department of Health. They are very dedicated people who are often called to emergencies outside normal hours of work; in that regard their hours are similar to those of politicians. Seldom if ever have general practitioners refused to answer a call even though they may not be on duty at the time. I am convinced, as are most members of the general public, that these are responsible people who are not taking action lightly and without full consideration of the consequences.

In recent years the workload of general practitioners has increased considerably. This is mainly due to action taken by the Department of Health. There is a policy at present to transfer psychiatric patients back to the community, and this is a welcome approach, but in many cases it is the general practitioner who has to take on the extra work of caring for these people. A balanced approach should be taken on this matter. The Department of Health must bear in mind that general practitioners do very necessary and important work in caring for people who were previously in hospital care. By transferring these people to the community they have a better chance of getting back to health and living a normal life.

I am glad to have this opportunity of pointing out to the Minister the almost criminal attitude taken by the Department of Health in regard to waiting lists. In the Midland Health Board area, people have been waiting for orthopaedic surgery in Tullamore Hospital for two to three years. Surgeons in that hospital are overworked and are under great pressure. General practitioners have to take on the work of caring for people who are in severe pain while waiting for surgery. These people contact politicians to see if they can speed up their operations but little can be done, as surgeons are under severe pressure. I know that plans are in progress but they are long overdue. I would stress to the Minister the urgency and importance of this matter.

As regards terminally ill patients who are cared for at home, here again the general practitioners has to be call on a regular basis to these people who in other circumstances would be cared for in hospitals or State institutions. Due to overcrowding in hospitals patients are released early and the general practitioner is called in to care for these people also.

I am sure the Minister is aware that in recent years great pressure has been brought to bear on young people due to examinations, unemployment and so on. This results in psychological complaints which again are dealt with by the general practitioner. In latter years the workload of the general practitioner has increased and the nature of the work has changed dramatically. I would ask the Minister and the Department of Health to consider this matter now as these problems should not be allowed to escalate.

I move amendment No. 1:

To delete all words after "that" and substitute the following:

"Dáil Éireann

—notes the recent arbitration award to doctors in the General Medical Service involving a significant increase of 17.5 per cent, implementation to be negotiated in the context of negotiations for the renewal of the 1989 Agreement;

—notes that the review of the GMS Contract has been under way for some time and that, in that context, the Minister for Health has brought forward innovative proposals for the development of general practice which take account of the realities of the budgetary situation and the constraints of the pay provisions of the Programme for Economic and Social Progress;

—regrets the decision by the Irish Medical Organisation to withdraw from the scheme while the review is continuing; and

—calls on the Irish Medical Organisation to withdraw its threatened action and to continue negotiations in good faith in a normal atmosphere free from the threat of withdrawal from the existing Contract."

I am glad to have the opportunity to speak on this motion regarding the current discussions with the medical organistions on the future of the GMS. I sometimes feel that in the intensity of discussions such as these, there is often a danger that we may lose sight of the fact that the patient should be our primary concern at all times. Therefore, let me assure Deputies, at the outset, that while I am confident of a successful outcome to these discussions, in the event of this not happening, the health boards will ensure that free general practitioner services and free drugs and medicines will continue to be available to persons covered by medical cards.

It may be helpful to Deputies if I outline in some detail the background to the present discussions with the Irish Medical Organisation and the Irish College of General Practitioners on the existing contract for GMS services. These discussions are taking place in a review of the services which is chaired by Professor Tom Murphy. This review commenced in March of this year. The 1989 contract, which is the subject of this review, represented a fundamental change in the manner in which general practitioners were paid in respect of services for medical card patients in that it changed from a fee-per-time system to a capitation based system augmented by a range of additional benefits. This change resulted in an estimated 16.5 per cent increase in GP costs. The bulk of these additional costs were attributable to:— a superannuation scheme (with a state contribution of 10 per cent of gross capitation income); payment of out-of-hours consultations; contributions towards the cost of employing nurses and secretaries; contributions towards locum expenses for annual/sick leave, study leave and maternity leave; early retirement arrangements; a doubling of the rural practice allowance and payment for a range of special services which had not been paid for before. Almost 100 per cent of doctors providing GMS services opted for this new style contract on the basis that it would be reviewed after one year and in March 1992. They all signed the new contract.

A review of the first year's operation and the new contract was completed in February 1991 between the Department and the Irish Medical Organisation under the independent chairmanship of Mr. John Horgan. This review covered both the service and financial consequences of the new system and clarified aspects of the original agreement at a further additional cost of about £4 million which was met in 1992.

Last year GMS doctors claimed an increase on all fees of 40 per cent to be paid retrospectively to 1 July 1989. Their claim was heard at independent arbitration in December 1991 and the arbitrator recommended, having regard to the very detailed case made by the Irish Medical Organisation, that these fees should be increased by 17.5 per cent with effect from March 1992 a date which coincided with the three year review of the existing contract. He further recommended that the implementation of the award should be negotiated in the context of that review. The Irish Medical Organisation formally accepted the arbitrator's recommendations on behalf of the GPs.

This award would cost an additional £11 million per annum, which would represent an average of almost £7,000 per doctor per annum, which would be due to be paid on the same basis as all other public service pay awards this year i.e. payment of revised rates on 1 December 1992 and retrospection from 1 March 1992 to be paid on 1 January 1993. The cost in 1993 of implementing this award, including retrospection payments, would be £20 million and the award would increase the average annual payment for doctors in the GMS to about £41,500. This average payment would, of course, only be in respect of the treatment of medical card holders who represent about one third of the population and would not take account of the potential private income available to general practitioners from the population not covered by medical cards.

As I have already stated, the present GMS contract provides for a review of its operation after three years. This review commenced in March this year. The Irish Medical Organisation are represented on the review with the Irish College of General Practitioners, the health boards and the Departments of Health and Finance.

At the outset it was made quite clear to the doctors' representatives that the review would be required to work within the parameters of public pay policy and that the main purpose of the review was to ensure: that a high quality of service was available to medical card holders; that the arrangements for the delivery of services to medical card holders were appropriate, adequate and cost effective; that structures were in place to allow for: the proper management and organisation of service, the control of costs and quality, with particular emphasis on the achievement of responsible prescribing, the effective co-ordination of the service within primary care services generally and effective working arrangements with other general practitioners, with hospitals and other institutional services; that the framework within which general practitioner services were provided for the total population was rational and cost effective in respect of the use of State resources. The review, therefore, would deal mainly with the organisation and funding of general practice rather than simply the payments to doctors.

Since the review commenced, there have been regular meetings both at plenary level and at sub-committee level which have dealt with a wide range of issues such as: the development of general practice, the organisation and management of general practice, prescribing in general practice, workload and expenses, right of entry to the GMS and rural practice. There has been very constructive dialogue on these issues and broad agreement in principle on the way forward has been reached. I assure Deputies that it is my intention to push ahead with the work of the review with a view to resolving outstanding issues through meaningful discussions within the next month.

As Deputies will be aware, I have had many years experience in the health services before I became Minister for Health. In that time I became convinced that many of the difficulties faced by Governments in meeting the increasing expenditure on the health services result from the major imbalance between the primary care and the acute hospital services. Health care delivery in this country is over reliant on the hospital sector where the emphasis is on expensive high technology medicine.

There is no doubt, in my mind, that a great number of procedures now being undertaken at hospital level could be more appropriately and cost effectively carried out by the general practitioner. It is my aim, therefore, to redress this imbalance and to restore the general practitioner to his rightful and central place in the delivery of health care within a fully integrated health care system.

Therefore, I see the development of general practice as a necessary and key requirement for the development of our health services. As part of this development it is necessary to broaden, where appropriate, the scope and depth of the general practitioners contributions to primary care and to improve the interface between general practice and the rest of the health services.

If general practitioners are to adequately fulfil the functions they are capable of fulfilling, the general practitioner service must be integrated with other health services to enable it to function as an integral part of the work of the health board in patient care. I also accept that doctors in general practice provide 24-hour cover for 365 days of the year and restructuring of general practice must take place to take account of this unique service.

To a large extent the difficulties in developing general practice stem from the fact that general practitioners, from an organisational point of view, are separate from the formal structure of the health services, and from lack of structural liaison between general practitioners, management and other sectors of the health services, due no doubt to the fact that they are private contractors to the health services. They contract to provide this service for general medical services patients, as opposed to the position in Britain where they are fully paid by the State for their services. As the House will know, here the medical card system caters for approximately 34 per cent of the population.

In more specific terms organisational and service problems arise from, first, the fragmentation of general practice and the isolation of general practitioners. Fifty-nine per cent approximately of general practitioners operate from single-handed practices with 15 per cent only operating from practices with three or more doctors, making it both difficult and costly to fund desirable developments. For example, general practitioners often work isolated from other general practitioners, or from community care services and hospitals.

Other problems arise from the lack of epidemiological data relating to disease process and morbidity within the community in addition to the lack of a defined practice population.

Since there is no definite list of private patients, the general practitioner in many cases does not know what his total practice population is in terms of either numbers or named patients. In the past, research in Dublin has shown that approximately 11 per cent of families with young children reported not having a G.P. A similar percentage attending at Dublin hospitals Accident and Emergency Departments recently reported having no G.P. at all. In the Dublin setting at least, the general practice population is not stable and a proportion of patients do not closely identify with one G.P. They freely change from doctor to doctor and practice to practice. To add to difficulties in practice organisation, in a proportion of families different members attend different doctors and practices.

Then there is the variation in practice styles. Variable issues include those aspects of the service with which the doctor is comfortable in dealing; what a doctor wants to do and level of investigation within practice. The setting of the practice, whether suburban, inner city or rural and the socio-economic profile of the panel also affect practice style.

Both sides in the review have accepted that general practitioner services should be organised in such a manner that they are capable of delivering a comprehensive level of primary medical care. It has also been accepted that if general practice is to fulfil its full potential: patients must be satisfied that the service available at all times is of a standard that normally avoids the necessity for them attending hospital particularly as a first point of contact; and the service must be seen to be capable of providing care. Therefore, patients and other health carers need to be assured that there is ready access to a general practitioner service which is appropriately equipped and which has satisfactory liaison arrangements with other health services.

Essentially, therefore, we need to shift the focus of health care delivery away from expensive treatment in hospitals to the primary care services and, more particularly, to general practitioner services. However, before such a reorientation can be achieved, the organisational problems within general practice need to be addressed. In this connection, I am satisfied that, if general practitioner services were organised properly, many of the shortcomings identified in the General Medical Service could be overcome; costs and workload would be reduced and funds freed up to allow for investment in the service. These are the reasons a high priority is being given to a resolution of these organisational issues in the current review. In attempting to meet my objectives for general practice, I would envisage that a number of different practice models would be introduced as follows:

First, group practice in urban areas and towns would normally be staffed by a minimum of three doctors in full partnership providing cross-cover for nights and weekends within the group and working from an appropriately-equipped medical centre. Within this centre, there would be facilities for doctors, practice support and other primary care services such as paramedical and social services. Such medical centres would either be provided and equipped by health boards or on a joint venture approach with general practitioners within agreed parameters. The level of equipment and facilities to be funded would be subject to agreement with the relevant health board.

Second, multi-centred group practices would apply in both urban and in rural areas and would involve either: (i) a minimum of three doctors working as a group in full partnership from different locations i.e. a doctor who resides and practises in an area would enter into a full partnership, providing cross-cover, as above, with two or more general practitioners in the neighbourhood. While each would have their own centre of practice, the group would have one central medical centre which would have equipment and facilities available to all members of the group, either by doctors practising there for specific planned sessions or by equipment being borrowed by GPs for fixed sessions. Equipment would be interchangeable between practices on the basis of agreement with the group; or (ii) any number of doctors who are located in proximity to a general hospital entering into a co-operative-type arrangement. All doctors in the arrangements would continue to operate from their own centres of practice but would agree to pool all resources, including staffing and equipment, and to provide full cross-cover.

Third, where group arrangements are not workable, for example in isolated areas, one or two-handed practices would be recognised and supported by the provision of incentives, provided arrangements acceptable to the health board are made with other practices for night and weekend cover. Access to equipment in group practices by these doctors would be encouraged.

In the case of all these arrangements it is recognised that a general practice requires support structures such as nurses, secretaries and access to sessional arrangements for various paramedical services and to a range of diagnostic and treatment facilities. Of course, the range of support structures necessary would be dependent on the type of practice arrangement entered into. I should say that, whenever a doctor would be given a grant towards the cost of a practice nurse, he would be paid in respect of the proportion of his practice only applicable to medical card-holding patients. He would not be paid a full secretarial salary if a proportion of his patients only were general medical service patients. Many doctors who never had secretaries before availed of the grant but, of course, incurred extra costs because they were provided with a proportion only of the secretarial salary in respect of their medical card patients.

A major portion of expenditure within the general medical service scheme relates to the cost of prescribing which in 1991, amounted to £120 million and which we expect to rise to over £130 million by the end of this year. As a result of the agreement drawn up between the Federation of Irish Chemical Industries and my Department, drug prices have remained stable here over the past two years. Notwithstanding that stability in prices, expenditure on prescribed drugs within the general medical service continues to rise as a result of increasing volumes of drugs being prescribed and the substitution of newer, more expensive drugs for older cheaper ones. These trends are an international phenomenon and are not unique to this country. Nevertheless they place heavy demands on the Exchequer and limit the scope for investment in general practice.

It has been accepted by the Irish Medical Organisation that the level of prescribing within the scheme could be reduced without any adverse effect on the quality of patient care. It has been agreed also that indicative prescribing targets should be determined for all doctors participating in the scheme, that is, indicative prescribing targets which are realistic. I readily admit that indicative prescribing targets were set for doctors, I think two years ago, which were totally unrealistic and which created great problems for them. Realistic indicative prescribing targets should be determined for all doctors participating in the scheme and a proportion of any savings generated from the operation of these targets should be applied toward general practice development.

I also hold strongly that a greater contribution toward the development of the public health services could be derived from other sources. In fact I would be very confident that such an increased contribution would materialise very shortly. I am heartened by the level of goodwill shown by the Irish Medical Organisation and the Irish College of General Practitioner representatives towards the establishment of measures aimed at achieving rational prescribing. I am confident that, arising from this review, workable arrangements will be put in place which will introduce more cost-effectiveness in this area.

In broad terms, therefore, my main priorities in the GMS review are the strengthening of the role of the general practitioner to enable a comprehensive primary care service to be provided for persons covered by medical cards; improving the interface between the general practitioner and the hospital and other institutional and community services; encouraging the development of more group practices and better cross-cover between existing practices in order to enhance the continuity of care for patients; and implementing measures which will result in safe and cost-effective prescribing. As I said these priorities deal with the service issues including the adequacy of the funding for general practice rather than simply payments to doctors.

I fully recognise the major role played by general practitioners in the overall provision of health care and I have been anxious in the review, to identify areas where their contribution could be enhanced in a cost effective way. Proposals have been put to the doctors which will significantly improve the quality and standard of general practice. Deputy Owen accused me of not bringing forward proposals. I would suggest that she listen to me. Of fundamental importance is that these proposals offer general practitioners, for the first time, a central role in the day-to-day functioning of primary health care services at both national and local level. I advise Deputy Owen to read the blueprint for general practice which emanated from my office. She would learn a great deal. I see these proposals as representing a blueprint for the development of general practice here over the next decade and I envisage that future GMS contracts will fit in with the strategy outlined in this blueprint. It is certainly encouraging that we have now reached a stage in the review process where agreement in principle has been reached on these proposals which I am glad to say both sides accept will be a major step forward for general practice. We should have a little less ráméis and a greater understanding of what is going on.

They would have withdrawn their resignations by now if what the Minister is saying is a fact.

I humbly suggest that Deputy Owen——

Gabh mo leathscéal, a Aire, Deputy Owen realises that she is completely out of order.

The Minister interrupted me.

The Minister did not interrupt the Deputy.


The Minister became very sensitive when I mentioned the word "misleading".

The Minister, without interruption.

I hope I will get injury time.

Reference has been made to the need for major investment in the GMS. I reiterate that the State has been investing considerable resources in the GMS — more than £190 million this year alone — and that this level of investment has significantly increased since the new contract was introduced in 1989.

Deputy Owen mentioned that the incomes of GPs have dropped since the introduction of the new capitation system. The total payments for doctors have increased from £44 million in 1988 to £56 million in 1991.

Their costs have increased too.

By my calculation that is an increase of more than 27 per cent.

What was the net cost?

I can only give official statistics.

What about their costs, Minister? I bet that if the Minister was still in private practice he would not be giving me those figures.

Total payments to doctors have increased from £44 million in 1988 to £56 million in 1991. That is before the arbitration award of 17.5 per cent.

What is the net cost, after tax?

Everyone pays tax. I would, however, accept the need for investment in the capital development of general practice if the policy objectives which I have already outlined are to be achieved. As I stated, if general practice is reorganised, it will be possible to relocate resources for the development of the service and the blueprint for general practice being discussed in the review sets out how this will be done.

In addition to the discussions on organisation and service development issues, considerable importance has been attached in the review to the broad area of the maintenance of standards in general practice. This is an area of particular concern to the Irish College of General Practitioners whose valuable contribution to the review process is very much welcomed by me.

While proper organisation and satisfactory conditions of service are very important factors in ensuring that quality of care is maintained at a consistently high level, professional training and updating of skills represent an equally important requirement.

It goes without saying that it we are to refocus health care delivery towards general practice, patients must have total confidence in the professional competence of their family doctors. Given that the largest group of students qualifying in medicine gravitate towards general practice, it never ceases to amaze me how little attention is given to this specialty at undergraduate level.

On the plus side, however, at postgraduate level, a general practitioner vocational training programme has been in operation here since 1972. Together with the continuing medical education scheme, these schemes, which are supported by my Department and the health boards, are vitally important if we are to ensure continued efficiency, effectiveness and morale in general practice. I share the college's wish to see these schemes properly co-ordinated and placed on a firm footing financially and I am confident that we will reach agreement on this important issue as part of the review. I am conscious of the wish of the IMO and the college to have a national forum for general practice where issues such as standards and manpower requirements would be examined. I consider that it will be possible to provide for such a forum within the organisational proposals which have been agreed in principle in the review.

My approach to the current GMS review discussions is similar to that of the doctor in the treatment of his patients. The doctor must establish the patients clinical history, carry out a full clinical examination, make a diagnosis and decide an appropriate treatment. Similarly, in the review we have analysed what has been happening to date in the operation of general practice with particular reference to the GMS; we have identified the shortcomings and their root causes and we have put forward proposals for overcoming these shortcomings. We put forward proposals for treatment. To approach the problem in any other fashion would inevitably result in further frustration on the part of both general practitioners and management and a recurrence of similar difficulties one or two years down the road. I want to avoid such a scenario at all costs and to put in place an agreement based on firm foundations.

My objectives would be, therefore, to reorganise and develop general practice along the lines I have outlined and create a general practice development fund of the order of £10 million from resources freed up from an agreed drugs strategy in the GMS and a greater contribution from other sources towards the development of the health services. I have got agreement to use this fund specifically for the development of general practice on the lines proposed. Another objective is to establish a specific general practice unit in the Department to oversee and monitor all aspects of general practice. The unit's staff will include a general practitioner medical officer who will be employed on a fixed term full-time basis. The unit will administer the practice development fund. The unit will also identify areas where general practitioners could cost-effectively perform work which is being done in other areas of the health service and develop policy for the development of the service: I can see these GPs carrying out health promotion programmes on a community basis throughout the country.

The establishment of a specific general practice unit in each health board whose staff will include a general practitioner is another objective. This unit will have a specific earmarked budget within which they will be required to identify a specific development fund. It will be concerned with all aspects of general practice including service delivery, practice support, drug budgeting and practice development. Guidelines on the operation of these units will be issued by my Department. The thrust of these units will be developmental in so far as their primary function will be to identify and correct the infrastructural deficiencies and shortcomings in general practice at the moment.

As the House will be aware, approximately 900 of the 1,600 doctors currently participating in the GMS scheme——

It is 1,000. The Minister's script says 1,000.

It is 960. I am giving the Deputy the correct figure.

The script says 1,000.

I know that, but I am correcting my Department. My figure is 960. The Department say approximately 1,000 but I am saying 960 because I know it and 960 doctors currently participating in the GMS scheme have served notice of their intention of withdrawing from their GMS contracts with effect from early December next unless progress is made in the review in meeting their aspirations.

In the light of what I have said, I am sure Deputies will agree that every possible reasonable effort is being made in this regard within the parameters set by public pay policy. My commitment to the development of general practice is well known. With the negotiation now at a crucial stage, let me assure the House that I will continue to seek solutions to the outstanding issues. My objective is to reach agreement with the IMO within the next month on my proposals and I am confident that I will have the goodwill of the doctors in meeting this objective.

In conclusion, I would again take the opportunity to allay any fears that might exist among medical card patients and to assure them that free general medical services will continue to be available to them from December.

Deputy Owen mentioned the case of an acute asthmatic but doctors have said that any person with an acute illness such as that need have no fears. Doctors and the IMO have gone to great pains to assure patients that they will not be deprived of medical care.

What about prescriptions?

The matter of extra visits to doctors to which Deputy Owen referred relates to the fact that patients were attending on a fee per visit basis and were attending more often because the doctors were inviting them back. There is a reluctance to operate under the capitation system but patients are conditioned in one way.

That is just not true. I am talking about the most vulnerable in our society. The Minister is not listening to what I am saying. He is twisting the point I made.

I ask the Minister to steel himself against his natural chivalry and ignore Deputy Owen.

I do not see much chivalry here tonight.

With the agreement of the House I can arrange that the excessive time, three minutes or whatever it is, will be deducted from the next Government speaker. That will solve the problem.

May I proceed?

Tá an t-ordú ann go gach éinne.

If I could be permitted to continue, I would like to assure the House——

Is it agreed that the extra time be deducted from the next Government speaker?

I have no objection to three minutes, but if the Minister is going to continue his speech——

Might I conclude my speech, please?

The Minister has already concluded his speech.

I was a general practitioner for a number of years. Both my daughter and my son are general practitioners, under the general medical scheme as are their spouses. Therefore, I understand the scheme very well and am sympathetic towards doctors operating within it. I have fought for them over the years and I assure them that I will continue to fight their cause, but I would appeal to them to withdraw their resignations and to continue the negotiations in an atmosphere of harmony so that we can sit down and together, address the wider issues of general practice. In that way when we reach agreement it will be in the best interests of doctor-patient care and the main beneficiary will be the patient.

That is an extra page to the Minister's speech.

I call Deputy Howlin. Four minutes will be deducted from the Government side. Deputy Howlin may have his 30 minutes.

I rise to speak on this motion tonight with a great sense of dejà vu. I have spoken on health issues in this House on a regular basis since I was first elected in 1987. That particular year was significant for health services. I regret the Minister is not remaining for my contribution but note that the Minister of State has arrived.

I am here to support him.

Deputy Roche's presence hightens my sense of dejà vu as he normally comes in to heckle.

In 1987 a general election was precipitated by health issues when the then Minister for Health, Mr. Desmond, refused to accept, and was supported in this by his Labour colleagues, a Health Estimate that would begin the process of cutting health expenditure. Mr. Desmond resigned because of the consequences that policy would have for our health services. The election was held and during the campaign the largest party currently in Government fought mainly on the health issue, festooning the country with billboards that have gone down in political history. These carried the message: "Health cuts hurt the old, the sick and the handicapped." On, as it transpired, the fraudulent basis that that party would not do anything to damage the health services but would, in fact, begin the process of building up and improving them, they were given a mandate; they did not get an overall majority, but enough to form a minority Government. What happened subsequent to that mandate has gone down in the annals of infamy. On assuming power that Government set about dismantling the health services. Within weeks of coming to office the then Minister for Health, Deputy O'Hanlon, set about closing beds and hospitals and laying off health workers, putting in train a sequence of events that has damaged the health services from that day to this.

In 1989 there was another general election during which the Taoiseach of the day admitted that he was unaware of the effects of the health cuts. Again, a health issue precipitated that election and some Members may remember that the issue related to fair compensation for haemophiliacs who had become HIV positive or who had contacted full blown AIDS as a result of receiving contaminated blood. The intransigence of the then Minister for Health and the then minority Government in their refusal to grant adequate compensation to that group of people, was the final shot which brought down that dreadful Government in 1989.

We are here again tonight addressing an issue which is of great importance to the health of every citizen of this nation. The motion ought to provide a useful and valuable opportunity for Members of this House to highlight a growing crisis that exists in a vital sector of our health services, the General Medical Service. It might have been possible for us to convince the Minister for Health of the extent of the crisis and the necessity for him to take immediate steps to resolve it but, unfortunately, this debate is taking place in a totally unreal atmosphere. The Government have been totally discredited by their own actions. As we speak, they are toppling from one political crisis to another. Seldom in the history of this State has there been such an unedifying, disreputable and undignified run-up to the collapse of a Government as we have witnessed in the past few days. By the time we vote on this motion tomorrow night — if we reach the stage of voting on it — the Dáil will be on the brink of dissolution and the nation will be facing a general election.

The Government need expect no comfort when they seek a mandate from the people. Since they have come into office they have demonstrated a complete lack of understanding of the pain and suffering their health policies have caused. Increasingly, they have shown nothing but contempt for the ordinary and valued democratic processes. They have no capacity, and probably never had, to address, in a manner that would mean something to the many thousands of families they are supposed to represent and support, the economic and social difficulties facing this nation.

The coming election may well be fought around the issues which have dominated today's headlines — Government credibility, honesty and decency, the so-called character issues which in recent days and weeks have played such a prominent part in the American presidential election, but I say to the Minister of State, that the minds of the electorate will turn very quickly to the economic and social challenges I have mentioned. Very high, if not the highest, on the list of real issues that will dominate the coming election and the concern of the electorate will be the decimation of the health services that we have witnessed over the last six years.

That is right.

You shake your head, Minister of State. I have seen Ministers of State and Ministers sit in the same seat since 1987 and shake their heads too.

Speak to the issue.

I am coming to the issue.

It has taken the Deputy a long time to get to the point.

The Taoiseach has said he was confident that adequate expenditure was being put into our health services and that there was adequate support for our GMS.

It increases every year.

Everything is increased in relation to inflation. In real terms what is the increase? I will quote figures in a moment. Complacent Ministers, such as yourself, have sat in those seats before only to understand reality when they were forced to knock on doors; that reality is not long away from you, Minister and your Government.

The monument to your Government can be measured in terms of long waiting lists, cutbacks in treatment and entitlements and the closure of essential facilities for old people, children and mothers. It would be an insult for anybody to come into this House and suggest otherwise. The complacency, indeed, the arrogance is an insult to those who are dependent on the general medical system and the health services in general. In cold statistical terms the continuing health care crisis can be summed up in the financial problems facing each of the health boards. It is worth putting on the record of the House, perhaps, for the information of the Minister of State, that every single health board faces a substantial overrun currently. I will give the Minister of State the figures for the first half year.

You did it yourselves in 1986.

You are talking in historical terms.

Fifty five million pounds.

You are responsible, Minister, do you not understand that? You and your party have been responsible since 1987. When are you going to realise it? You cannot look at history forever.

Deputy Howlin should appreciate that he is addressing the Chair and he is attributing to me power on matters I am not aware of when he uses the word "your".

Perhaps the Chair could prevent the Minister from interrupting me constantly and then I will not have to address anybody.

An Leas-Cheann Comhaiarle

If the Deputy persists in addressing the Minister he runs the risk of being interrupted. If the Deputy addresses the Chair I guarantee that the Chair will not interrupt and will not allow anybody else to interrupt.

I will put that to the test now. I will quote some figures for your information and for the information of Members of the House. For the first six months of this year deficits for the health boards are as follows: the Southern Health Board, £2.216 million; the NorthWestern Health Board, £0.5 million; the Mid-Western Health Board, £0.95 million; the North-Eastern Health Board, £0.895 million; the Western Health Board, £0.243 million; the South Eastern Health Board, £0.946 million and the Midland Health Board, £0.375 million. I do not have the exact figure for the Eastern Health Board because they did not supply the figure, but I understand it is well in excess of £5 million.

It is about £7 million.

Altogether, there is approximately £11 million in overruns in the health boards' expenditure for the first half of this year. That can only be described as an interest free loan commandeered by the State at the expense of each and every health board, ultimately at the expense of the services that this House charges those health boards to provide, and that, increasingly, simply do not exist. Orthodontic treatment, hip replacements or such services that are available are now becoming rare increasingly.

Those figures take no account of moneys already owed by health boards. They amount in total to a major burden of debt which is crippling the effectiveness of health boards today and will continue to do so in the future. It makes salient reading to look at the minutes of health board meetings. If I may say, through the Chair, it would be instructive reading for the Minister and the Minister of State.

That is the background against which we discuss the crisis in the general medical service. There is no point in the Minister telling this House that the allocation for the general medical service has been increased this year. The reality is that for most of the last five years the allocation has been systematically cut by the Department in real terms. The only reason behind the increases in expenditure has been that the demand-led schemes operated by the general medical service have been stretched beyond breaking point. This has happened because of the other cutbacks within the health care area. The pressure has now been put on the GMS. It is a classic case of the sick subsidising the sick. As geriatric beds and hospitals are closed, more pressure is put on the GMS system and the local doctor to meet needs that were previously met by other elements in the health service but which are no longer available because they have been discontinued by the health boards due to lack of money or directly by Government action.

The problem is now compounded by the dispute involving general practitioners within the general medical service. It is all very well for the Minister to point to an arbitration award, as he did tonight. In the normal course of events an arbitration award of 17.5 per cent would receive considerable welcome from general practitioners. The difficulty in this case, as the Minister is aware, is that the award of 17.5 per cent is not the issue. If the Minister was present, I would say to him, through the Chair, that as a former general practitioner he must be familiar with the cash flow problems from which many general practices suffer. It is abundantly clear from discussions we have all had with practitioners around the country that the problems I have mentioned have been exacerbated for many practices by the retention tax that is applicable to all earnings under the GMS. In other words, in the operation of the health services generally, the Minister is expecting sick people to subsidise other sick people. The Minister expects general practitioners to subsidise the operation of their practices in so far as medical card patients are concerned from whatever income they receive from their private patients.

That is right.

It will come as a surprise to some, perhaps to the Minister, that the Labour Party are aware of and concerned about the difficulties faced by general practitioners. It is probably true that none of us knows very many doctors who are poor but we have a very fine GP service, one we are all proud of that we will seek to maintain and expand. It is a service in which the people repose a great deal of trust. It reflects very little credit on this Minister or this Government that they have done damage to that fundamental trust. They have forced doctors into a situation that in the near future general practice services may only be available to those who can afford them. That is sad and unacceptable.

In relation to the current situation in the general medical services scheme, it is salient to talk of the difference that is now being made between private and public patients. When the system was set up both types of patient were treated identically. Whether a patient was fee paying or a medical card holder made no difference to the quality of care and attention they received. Unfortunately, that is no longer the case. There has been a change, particularly in relation to preventive medicine. There is a number of procedures that those who are private patients would normally seek, such as, smears, cholesterol tests, smoking cessation programmes, breast examinations, etc. These preventive measures, so important in modern medicine and available to private patients and accepted as routine, are now becoming increasingly rare for medical card holders. The great paradox is that where they are needed most, that is, for those who are dependent on the GMS — mainly the unemployed and the elderly — they are least available and where they are least needed, for the more affluent elements of the community, they are most readily available. That is a sad position.

Debate adjourned.