Léim ar aghaidh chuig an bpríomhábhar
Gnáthamharc

Dáil Éireann díospóireacht -
Wednesday, 26 Oct 2011

Vol. 745 No. 1

Health (Provision of General Practitioner Services) Bill 2011: Second Stage

I move: "That the Bill be now read a Second Time."

I am pleased to have the opportunity to address the House today but saddened that all the Opposition benches are empty because this is an important Bill.

They are on holidays.

It is Second Stage of the Health (Provision of General Practitioner Services) Bill 2011. It means that if suitably qualified general practitioners decide to set up practice not alone will they be able to treat private patients from day one, but also they will be able to treat patients holding both GP visit cards and full medical cards. There will be no limit on the number of contractors.

The new changes are being introduced on foot of the commitment in the EU-IMF programme which required the introduction of legislative changes to remove restrictions to trade and competition in sheltered sectors, including eliminating restrictions on GPs wishing to treat public patients. This was part of pre-election pledges made which are now being rightly honoured because as I pointed out the restrictions have had a detrimental effect in the past regarding the ability of younger, properly qualified GPs to set up in practice and deliver care and service to their community. In many instances in the past it was the difference between GPs deciding to stay in this country or to emigrate, and that has been to our loss also.

The current position is that GPs can only obtain GMS contracts in restricted circumstances where a vacancy arises due to the retirement, resignation or death of an existing GMS doctor; where a new GMS panel is created in response to an identified need for an additional doctor in an area; and where a GMS doctor obtains approval from the Health Service Executive, HSE, for the creation of an assistant with a view to partnership within his or her practice.

The HSE is currently required, before filling a vacant GMS panel or creating a new panel, to take account of the potential viability of the panel being established and the viability of existing GP practices in that area. The arrangements I have described prevented many young, highly qualified and trained GPs from obtaining a GMS contract early in their careers. The current system allows them to treat private patients but they are not able to treat medical card or GP visit card patients until such time as they obtain a contract from the HSE. They may have to wait several years for such an opportunity to present itself. That meant in practice, particularly in the recent economic climate, that GPs who were restricted to private practice could no longer look after patients and their families when they fell on bad times through no fault of their own due to the economic changes we have experienced and the downturn in which this country finds itself. Consequently, they had to find a new doctor when often they had no wish to do so because they had a relationship with their existing doctor. They also had to undergo a re-examination and a further full divulgence of their history, which can be particularly traumatic for people who have psychiatric or psychological problems. It is difficult to start one's story all over again with a new doctor when one's own doctor understands one's situation, knows one's history and with whom one feels comfortable.

In addition to the above, two other categories of GPs have certain restrictions placed on their rights to take on and-or retain GMS patients under the current arrangements. These are GPs who hold a GMS contract on foot of interim entry provisions put in place in 2009 where they would have to wait until 2013 before they could treat any medical card or GP visit card patient; and certain GPs involved in a partnership which is being dissolved or terminated before a specified period would not be allowed to retain the patients on their GMS list at the time of dissolution of the partnership. The Bill will remove these restrictions.

When this Bill is enacted, new GMS contract holders will be free to establish their practice in the location of their choice. However, a contract holder approved by the HSE in an area who wishes to move location may only do so with the prior approval of the HSE. This is designed to ensure continuity of care for patients and ongoing convenience from a patient's perspective.

I will outline some of the provisions of the Bill and the sections therein. Section 1 provides for the definition of certain terms used in the Bill. Section 2 provides that the HSE will be entitled to enter into a GMS contract with any suitably qualified and vocationally trained GP and it will not be limited to granting contracts where a GMS contract holder dies, retires or resigns from the GMS. I emphasise that GPs will have to be suitably qualified. There is no question of this being a back door for any inferiorly trained GP. Equally, I would point out that many of our young GPs in practice in private medicine are as qualified as their peers in the GMS but we must put in place controls to ensure that the people have the required training and qualification or equivalent training as recognised by the Medical Council and the Irish College of General Practitioners.

Section 3 provides that GPs holding a GMS contract will be entitled to accept onto their list any patient nominating them as their doctor of choice, subject to existing rules relating to panel size. These rules stipulate that the total number of GMS patients which may be placed on a GP's list shall not exceed 2,000 save where the HSE or such organisation as follows it, in exceptional circumstances, decides to apply a higher limit. This will ensure that GPs who hold a GMS contract on foot of interim entry provisions put in place in 2009 will, from the date this Bill is enacted, be able to take any medical card or GP visit card patient onto their list and they will not have to wait for two more years before doing so.

I would point out that the choice of doctor scheme has been one of the great successes since the 1970s and we want to increase that choice to the patient. It has empowered patients in more recent decades in that they do not feel they have to stay with a single GP as they did in the old dispensary system. It also creates competition among GPs to be more cost effective and to deliver the range of services people want in a modern society, and the more doctors we have the better from that point of view.

Section 4 provides that when a partnership dissolves, a GP who wishes to continue participating in the GMS scheme may retain the patients on his or her GMS list on the date the partnership dissolves or terminates, unless the HSE is advised that any such patient does not want to remain on that list. Section 5 provides that the HSE, when filling or creating a GP position, will not take account of the short-term or long-term economic viability of that or other GP practices. This will address a recommendation in the Competition Authority's July 2010 report on general medical practitioners, which was aimed at increasing competition within the GMS scheme.

Section 6 provides that where a GP has been approved by the HSE to provide GMS services at a particular premises, he or she cannot provide such services at another premises, unless he or she has submitted a request to the HSE and the HSE has given its consent. Therefore, a contract holder who wants to change his or her centre of practice can only do so with the prior approval of the HSE. Section 7 provides that when this Bill is enacted, nothing in the Act will affect the operation of the GMS scheme, other than the provisions set out in sections 2 to 6 of the Act. Section 8 provides for the Short Title and commencement of the Act.

In conclusion, the programme for Government provides for significant strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients. This commitment will be achieved on a phased basis to allow for the recruitment of additional doctors, nurses and other primary care professionals. I and Deputy Róisín Shortall, the Minister of State with responsibility for primary care and the first such Minister in the history of the State, will oversee the implementation of this programme with the assistance of a project team of officials from the Department and the HSE.

I am confident this legislation will contribute to this commitment as it will encourage more young GPs to remain in Ireland and to establish their practices here, and it will make it more attractive for GPs to move here from overseas. It will also encourage competition among GPs at a time when many fee paying patients have less money at their disposal. Furthermore, it will answer our manpower problems. This legislation in conjunction with the plans for a new GP contract will address many of the issues that afflict our health service.

The health service operates as a whole and no single part of it operates in isolation. Consequently, if there are not enough GPs, the pressure is felt in emergency departments. If there is pressure on those departments, it is felt in the hospitals, and if there is pressure in the hospitals it will be felt in long-term care. No single part of the system acts alone, so the entire system must be addressed. We must address the deficits in primary care, in terms of manpower, the type of work it does and how it works. We must address the situation in the hospitals and how our consultants, non-consultant hospital doctors, NCHDs, nurses and ancillary staff work. We must also address the issues of home care, long-term institutional care and other models of care that are interim in nature and can be very successful in addressing the needs of our citizens.

That is the reason this Government has taken its own approach and made it clear that it might take longer than one term of office to bed the system in. I believe that shows a political maturity that has not been to the fore until now.

Generally, people have looked for a quick-fix, one-off solution one election at a time. We have taken a longer and more mature view. We want to fix this system and fix it for this and the next generations, not provide a short-term solution that will result in chaos in a couple of years.

This Bill is just one part in a myriad of legislation that will be brought before the House in the next couple of years. I hope the Opposition can support it because I believe its Members also wish to have a health service in which patients feel safe and of which those who work in it feel proud.

I welcome the publication of the legislation to deal with the GMS and to lift restrictions on GPs accessing the scheme. The Minister's speech was fine until the end, but I will refer to the comments about quick fix solutions later.

The Minister makes the valid point that the health service must be seen as a single system in which all parts must work in unison and where there is a streamlining of resources to ensure best patient safety and outcomes from treatments. The GP is an integral part of that front line service. There is now a stronger emphasis on creating primary centres and on them being the front line in the delivery of health services in this country. I welcome that. It is something all sides of the House have supported over the years. To implement it obviously entailed huge challenges. There were difficulties with securing the buy-in of medical professionals, locating premises and with the roll out of primary care centres throughout the country. It is a work in progress, and many of these things took more time than originally anticipated or envisaged due to certain blockages, even in the context of planning issues in certain local authority areas.

In general, anything that not just fosters competition but makes the health services more efficient, effective and responsive to the needs of people and our communities is very welcome. This Bill is welcome legislation. As the Minister said, it is in the programme for Government, so he must be complimented on that. Of course, it is also in the IMF programme, which was probably a stick as well as a carrot for delivering it. However, I welcome the fact that it is here. There are concerns on the part of some GPs who might feel their businesses could be diminished. The health services, however, are first and foremost for patients and we should work from that premise back, rather than the other way around, as was the case for many years. That is welcome.

I have a few queries about the Bill. They are not criticisms so the Minister should not take them in that way. Sometimes we can be accused of criticism when we are being constructive. We will deal with section 6 on Committee Stage but has any analysis been carried out over a number of years to ascertain if there has been a move on the part of GPs from areas with socio-economic challenges and from rural areas? There is nothing in the legislation to provide that if doctors access a certain number of GMS patients, there is an obligation on them to ensure there are a certain number of surgery hours available in a particular place as well as an out-of-hours service. In Dublin, for example, there are still difficulties with the provision of out-of-hours services.

There are some very successful co-operatives across the country and they have been embraced by the people. Once that system is set up it works very well. SouthDoc in Cork, for example, is a model of the co-operative system, with doctors coming together to provide an out-of-hours service. There is no criticism in Cork of the SouthDoc out-of-hours service. Could this legislation undermine that co-operative element? Has there been any such analysis? I am not saying it will, but has there been an analysis of whether there might be a drift from socio-economically challenged areas and rural areas in that context?

On the broader issue, there is still a difficulty with the number of doctors coming through education, training and qualification. As the Minister correctly pointed out, a large number of our non-consultant doctors and GPs are heading abroad as well. That is a huge loss of talent, expertise and investment. We saw the difficulties this year in recruiting non-consultant hospital doctors. We were obliged to bring people in from abroad. They were welcome but at the same time some of our doctors were going abroad, reluctantly rather than in the interest of furthering their careers and broadening their horizons in terms of training and access to other ideas and innovations.

There is also the issue of the restrictive nature of the training of doctors. Obviously, it is critical that one has the best training and educational facilities, standards and attainment but as we roll out primary care and it becomes the front line, the number of GPs available to provide that front line service must be examined. Somebody said a few days ago that there are twice as many solicitors as GPs in this country, so perhaps we are out of step. I am not criticising solicitors but, all things being equal,——

I hope it is not a reflection on GPs either.

——it is an issue we should examine.

On the broader issues of primary care and home care, as we move towards the idea of more home care supports we must not lose the traditional relationship between a GP and a patient. If a person wishes to remain at home, there must be some encouragement beyond the dedication of the doctor and their commitment to their patients. There should be an incentive that they would buy into the whole idea of supporting home care packages and assisting people to remain at home for as long as possible. If we want to get people out of the acute sections of hospitals after procedures into step-down facilities and back to their homes as quickly as possible, the GP will have to play a role in supporting them in convalescence and equally if they are at home.

While we have health promotion in Ireland to reduce tobacco and alcohol consumption, obesity is becoming an issue that is of concern in view of the pressures it puts on individuals in the context of heart disease, diabetes and many other complications. As a society we must become more embracive of healthy living across all sections. This is not just about promoting sport but the concept of health should form part of normal life in primary and secondary schools, in dietary, in nutritional education and in home economics. The PE curriculum should be extended and the GP should be at the centre of health promotion not only in the context of encouraging people to give up cigarettes, but that it becomes part and parcel of health provision. There should be a consciousness that a healthy lifestyle, activity and diet are all part and parcel of a package. Everybody would accept that if we continue as we are, even though efforts are being made in the context of the health services promotion unit and the control of tobacco, it is still haphazard or disparate at the very least. There is a need for a strong and co-ordinated effort through schools, sport facilities, local authorities, the health services and across the whole gamut of agencies, Departments, civil society and the community and voluntary sector.

When travelling around the country one becomes aware of nice amenities and walking areas and the promotion of that type of activity. The GP and primary care centres must play a central role in the development of this concept. I visited Australia a few times on trade missions. It was evident there that all of society had bought into the idea of healthy living. I appreciate it has a nice climate and it is more conducive to outdoor activities, but I could sense the healthy lifestyle, the abhorrence of tobacco in the context of it being socially unacceptable and the promotion of healthy foods in all its aspects. That is a critical issue. I may be straying from the Health (Provision of General Practitioner Services) Bill 2011 but if we develop this theme in our minds and in society it will benefit us in the years ahead.

The issue of obesity must be challenged head-on given that the statistics for same are quite alarming. We have only to look at the country that now sets a precedent for western world living in the context of changes in attitude and behaviour and how we live. The US is experiencing enormous difficulties and challenges in that context. In the coming years I hope that calorie count legislation, or the use of some mechanism and changes in attitude and behaviour will enable us address this issue before we allow a generation to be robbed because of our inactivity in addressing this challenge. These are key areas that build into primary care being at the centre of where health services are delivered and where healthy lifestyles and options are encouraged and promoted.

In most GPs offices, the health promotion unit has stickers on the wall, perhaps showing people running up the road or another sticker showing somebody else trying to give up cigarettes. This has to be at the heart of health promotion. As a GP, the Minister sees that at first hand. Wherever he can, I ask him to develop a policy and a theme around the whole idea of healthy living.

Obviously GPs are the front line service providers along with nurses. Once primary care units are established, lines of demarcation and barriers in the context of professionals having certain trenchant views on certain issues will become a challenge in itself. Nurses, because of their training and qualifications, are moving into areas which traditionally would have been the GPs remit. While I welcome this, it is an issue that creates friction. I suggest we look at that issue in the context of setting up a single primary care unit with many different professionals, eminently qualified, all providing health services and working, hopefully, in harmony and unison. However, that is not always the case as has been identified even in some hospitals where there are differing views and people who may not have the best people and management skills.

I welcome the Bill. The lifting of restrictions will allow more GPs to establish and provide good quality front line health care to patients. My only concern, which I ask the Minister to look at in the context of the Committee Stage debate, is that if there is a complete opening up there must be a mechanism to ensure that out-of-hours service is provided and that a certain number of hours of GP service is available. A former Member and party colleague, Mr. Charlie O'Connor, sent me a note today, not being aware this matter was being discussed, on the shortage of GPs in Tallaght. I do not know why that is the case. Is it because of the socio-economic make-up or that it is a new evolving growing town and that the restrictions heretofore of doctors accessing the General Medical Services scheme have allowed this to happen? We should be concerned if there are not enough GPs delivering front line services in areas such as Tallaght, which has many young people, young mothers and children, because that could create its own difficulties. It is possible that impacts on the pressures at Tallaght hospital. If people cannot access GPs in a reasonable time, they present at accident and emergency departments which, in itself, can create further difficulties and pressure points in those departments and a follow on of the difficulties Tallaght has experienced recently. I hope we can have a more clinical debate on Committee Stage.

I do not wish to appear like a puritan or a persecutor of people who like to enjoy themselves. In encouraging a reduction in the use of tobacco there is one view in the Health Service Executive about raising excise duties and tax on cigarettes in order to reduce consumption, and on the other side of the argument those in Revenue and the Department of Finance highlight the fact that the more one increases taxes the greater are the diminishing returns to the Exchequer because of smuggling. I am not sure which argument wins but reports have been carried out by the Irish Heart Foundation and the Revenue Commissioners.

I am not in favour of hiking up the price of cigarettes for the sake of it. If prices are to be increased as part of a health promotion policy, then the revenue generated should be used to encourage people to give up cigarettes. Consideration could be given to the provision of supports and assistance such as nicotine substitutes. I say that as a person who has battled with the weed on and off since I was 14 years of age. It is easy to give up cigarettes. I give them up regularly. Many people require more than just a direction or encouragement by a doctor to give up cigarettes. Supports other than a helpline are required such as nicotine substitution. Supports such as nicotine substitution are provided by the National Health Service in the United Kingdom. We should examine that possibility. If we decide to go for a hike in taxation to discourage the use of cigarettes, the revenue should be used to encourage people to give up cigarettes. I wish the Bill a speedy passage. I hope that its intention will be brought to fruition and that what the Minister outlined will come to pass also.

The Bill comes before the Oireachtas in, arguably, the worst possible circumstances. It reflects no credit on the Government or on the Oireachtas as a whole. The sorry fact is that the Bill is before us because our International Monetary Fund, IMF, European Central Bank, ECB, and European Union, EU, economic masters insist on it and the Government has to comply.

Setting aside the merits of the Bill itself for a moment — it does have merits — it is a sad spectacle to see a piece of legislation in the vital area of health care having its genesis in this way. It will only add to the cynicism of many citizens about Irish politics, a cynicism that diminishes all in political life — the principled, progressive and hard working as well as the careerists and incompetents. It will be said that it took the IMF to come in to deliver an overdue reform that Irish politicians could not themselves deliver.

I said the Bill has merits and it clearly does. Access to the General Medical Services, GMS, scheme for GPs is far too restrictive. The Minister knows that better than probably anyone else in the Chamber. Many who wish to treat GMS patients cannot do so because of the exclusivity of the current arrangements. The need for change has been widely recognised, although there is division within the medical profession on this, with some arguing for the status quo, but there can be no doubt in anyone’s mind that the status quo is not tenable and it must change. One could ask why it has to change. It is clear that it is not serving patients as well as it should. There are too few GPs overall and too few GPs have access to GMS contracts which allow them to treat medical card patients. The problem is one of the core difficulties in our primary care system and it must be addressed as part of an overall patient-centred reform and rebuilding of primary care on the basis of need, equity and, importantly, efficiency.

The changes brought about by the Bill can form part of this rebuilding process but, as I have already pointed out, that is not the reason they are being advanced now. The IMF, ECB and EU has insisted on the changes not for reasons of health care, but, in their words, to "increase competition". The intent of the changes is to remove "restrictions to trade and competition". This is about supposedly increasing economic activity in the area of primary care by making available the State supports under the GMS contracts to more GPs. It is not about improving health care outcomes. If it improves health care outcomes — that is an open question as it is yet to be seen — it will do so incidentally and not as part of a primary care strategy or an overall health strategy on the part of Government. It may well increase or at least keep up GP numbers. It may keep more young GPs in Ireland because they will now have access to the GMS system, but a much more comprehensive approach is needed. I believe the Minister knows that and I hope that would also be his intent.

There is an acute shortage of general practitioners in this State and that is one of the most serious problems in our health service. We have approximately 52 GPs per 100,000 population; France has 164, Austria 144, and Germany 102 GPs per 100,000 of population. We also have a situation in this State where some areas — especially disadvantaged areas — have far fewer doctors per head of population. For example, Tallaght, is one such area. The former Deputy, Mr. Charlie O'Connor, was just mentioned. Heaven forbid that I would not mention Tallaght, because he surely would. In Tallaght there are only 24 GPs for a population of 71,000. That is hugely below even our low State-wide level of provision.

An ESRI report in 2009 showed that in terms of GP distribution, Cork — Deputy Buttimer should take note — Galway and Waterford are better supplied with an average of more than 65 GPs per 100,000 of population, while Clare, Offaly, Laois, Meath, Kildare and my home county of Monaghan have the worst ratios at less than 45 GPs per 100,000 of population. The ESRI predicted that Dublin, Limerick, Tipperary south and Monaghan, gladly, will fare better from now until 2021. The worst served counties will be Meath, Laois, Cavan in my constituency and Wexford. By 2021, it is projected that Meath will have only 27 GPs per 100,000 of population compared to 63 in Cork. Kildare and Laois will have little more than 30 GPs. There are further wide variations in our cities, as I have already highlighted with regard to Tallaght in Dublin. These are worrying indicators.

The question is whether opening up the GMS scheme, without other measures, addresses the overall shortage of GPs and, crucially, if it addresses the unbalanced distribution of GPs which leaves many communities so poorly served. We do not know the answers to those questions but what we do know is that a market-based approach will not ensure balanced distribution of GPs and an adequate service for all communities. It could well see an even greater concentration of GPs in more prosperous areas where there are, for example, a high number of older GMS patients and a potentially bigger pool of fee-paying private patients.

This all points to the need for a comprehensive planned approach to primary care, an approach that is still sadly lacking. The Minister for Health, Deputy Reilly, was a member of the Oireachtas Joint Committee on Health and Children in the previous Dáil, which produced a comprehensive report entitled, Primary Medical Care in the Community.

That report on primary care was an indictment of the previous Government's record on health care delivery, and a very valid indictment it was. It presided over a totally inadequate primary care infrastructure which it was far too slow to develop and improve. As long ago as 2001 the need for 600 primary care teams across the State was identified in the Government's own health strategy. By the end of 2009, only 112 teams were at an advanced functioning stage. This is a disgraceful record.

The committee report also highlighted the shortage of trained GPs and the inordinate delay in bringing forward essential health legislation, such as that providing for information for patients, and the promised Bill to define people's eligibility for health services, which I have raised on the Order of Business time after time. The report correctly stated that the current primary care accommodation infrastructure is outdated and inadequate for the provision of modern services. The report's comprehensive set of recommendations cover GP training, developing the role of nurses, ensuring skills mix in primary care, expanding pharmacists' role and prioritising community mental health services. The report recognises that the provision of primary care centres is essential. Deputies are of one voice on that matter.

Very significantly the report opposes the corporatisation of the development of the new primary care infrastructure. The danger of corporatisation is one of the concerns raised by some medical professionals in the context of this Bill. If the Minister is following the exchanges on the proposed legislation in the various medical journals, he will be familiar with what GPs and others are saying. Writing in the Medical Independent on 8 September, Dr. Raymond Walley, a Dublin GP, expressed the view that as big companies in the health care area are specialists at tendering, such corporations will win GMS contracts, allowing them to utilise GPs as employees.

The report of the Joint Committee on Health and Children, which I have just cited, was very clear on this. It states the following in its recommendation No. 14:

The committee strongly opposes the "corporatisation" of the development of new primary care infrastructure. It recommends that a system of incentives be provided that would result in: the development of primary care centres by professional members of the primary care teams who will be directly involved in each centre and; the exclusion of large-scale corporate interests from such incentives.

I am of one mind with that view.

The Government has promised free GP care for all within its term of office. That is a very big commitment. It is one my party and I fully support and have long advocated. However, there is very little sign that the Government has even begun to put in place all that will be required to deliver on it.

The Minister of State with responsibility for primary care, Deputy Róisín Shortall, admitted earlier this month that the Government does not yet know how many additional GPs will be required for the new free GP care system. That is crucial information. She said the study of the additional number of doctors needed would be completed by the end of this year. Perhaps she, or the Minister in his closing remarks, can confirm this and give us an approximate date for when the report will be published.

The Government needs to recognise that a comprehensive study is also needed to identify where, as well as how many, GPs are needed. Where is just as important as when. Indeed, such a study is essential. The Minister of State acknowledged that there are what she called blackspots where there is a shortage of GPs. I have just cited some examples of these blackspots. These need to be clearly identified throughout the jurisdiction. Measures need to be put in place to remove those gaps. We need good planning and good implementation of an effective primary care strategy to ensure that all communities are served equally and that every citizen has access on the basis of need and within easy reach of where they live.

The Bill addresses only one aspect of the problem of primary care delivery. As another GP stated in that Medical Independent debate which I cited:

The system is flawed in so many ways that my fear is that resolving the GMS access mechanisms may lead those in positions of power to say "Phew! That's the GMS system sorted", when in reality it is just the tip of the iceberg.

No previous Government ever promised more on health care to the electorate than this Fine Gael-Labour Party coalition. Good for them. However, it is the delivery and the implementation that Opposition voices must watch and mark them on. In these times we understand the difficulties but we have yet to see the colour of their money. That is what it will come down to and so far the signs are not good. The cuts imposed by the Fianna Fáil Party and the Green Party are continuing and even worse is in prospect if we are to believe half of what might present in the 2012 budget on 6 December.

The Minister has contradicted his own words when in opposition regarding the dire impact of bed closures. Last night, I pointed out the relevant quotes and how his position has changed since he left this side of the House and took up his seat on the other side of the Chamber. There is no doubt that he is bringing private management into two of our largest hospitals. These are not small developments in Galway and Limerick. He cannot tell us when the promised White Paper on universal health insurance may be published, although it was supposed to be early in the lifetime of the Government. That is what we were given to believe.

I will not oppose the passage of the Second Stage of this Bill. I hope I will be able to support it on its way through the House. However, the GMS system needs to be opened up. While the Bill serves that purpose, it does not deal with all the issues. The Minister knows that. The points I am making are absolutely valid. I do not criticise for the sake of criticising.

I have noted the comments of others in this debate and in the various medical periodicals. A totally free market, laissez-faire approach to primary care or to any aspect of our health care system will only make matters worse. Therefore, I have reservations regarding the Bill and I will endeavour to address these on Committee Stage in the hope that it can be improved and strengthened. I would welcome the Minister giving consideration to the concerns I have expressed and those of others who are within the GP cohort serving our respective communities across the State and explore what can be done to strengthen the Bill as it makes its way through the Oireachtas.

With the agreement of the House I will share time with Deputy Finian McGrath.

I am glad to have an opportunity to speak on this Bill, which I welcome. It is hoped it will be helpful in the development of our primary and community care services. Everyone in this House is of the view that the development of primary and community care services is essential to the proper delivery of health care in this country. I support the development of services in the community to the largest extent possible, be it care of the elderly, mental health or general medical services. Community-based services are key to health service delivery in this country. This does not, however, mean we can dispense with hospital-based services. The driver of proper service delivery in this country is the development of community and primary care services.

While our health services have not been developed to the fullest extent possible, there has been much development in the community and primary care area. I compliment the voluntary organisations involved in care of the elderly. Services such as meals on wheels, day care centres, the Society of St. Vincent de Paul and other church-based organisations, senior citizens organisations and sheltered housing ensure our elderly can continue to live in their homes and communities. While the services provided by these organisations are excellent, they need to be developed further.

The delivery of primary care centres and primary care teams is important. A previous speaker spoke about delivery through the various primary care centres of not only medical services, but ancillary services such nursing, OT and dietetic services and the development and provision in these centres of a holistic health service for people within the community. I agree with his remarks in regard to preventative health services in respect of obesity, smoking, lifestyle, diet and so on. There is no doubt but that community care is key in the delivery of health services. While there have been some good developments, more needs to be done. This Bill, while only a small part of that process, is a positive part of it.

We need to address the issue of location of general practitioners and to increase the average number of general practitioners per head of population here. As stated by Deputy Ó Caoláin, the average number of general practitioners per head of population in Ireland is 52 per 100,000. In France there are 164 per 100,000, in Austria there are 144 per 100,000 and in Germany there are 102 per 100,000. The figure of 52 per 100,000 for Ireland masks areas with substantially fewer people. It can be difficult to get GPs to locate on a permanent basis in rural areas. It is often difficult to get them to fill short-term vacancies in rural areas. Many large urban disadvantaged areas are not adequately covered to the extent they should be based on the average number of GPs per head of population. Perhaps the Minister will, when responding, reply to the following question. Can this Bill be used to direct GPs who come into the system under the General Medical Services scheme into rural and large urban disadvantaged areas, which are currently only served by a skeleton service?

I note that under this Bill new general practitioners will be initially allowed to choose their location but will not be able to change their location without approval from the HSE. Could a similar provision be included to provide that GPs could be directed or——-

Incentivised or encouraged.

——to locate in areas where we are currently experiencing difficulty getting GPs? We continue to have difficulty in regard to the numbers of general practitioners in training. To increase the figure of 52 per 100,000 will require the training of additional general practitioners. This issue will need to be addressed.

I believe the limits for medical cards need to be urgently amended. The current limits for medical cards have not been changed in the past five or six years. While no problem arises in respect of families whose sole income is social welfare, there are significant difficulties in respect of families whose only income is from low paid employment.

The medical card limit for a single person living alone and working is €184 per week, taking account of rent and so on. As I stated, these limits have not been increased since 2006. The current limit for a medical card for a married couple under 65 years of age is €266.50 per week. The limits are simply out of date. We will probably be told that the number of medical cards granted in the past 12 months, or even two years, has increased substantially. Of course it has, but it has increased because of the number of people on the unemployment register and whose sole income is social welfare. Applicants who are working, in particular those in low paid employment, are being disadvantaged by the current limits and I ask the Minister to look at them and increase them accordingly. As I said, that has not been done for quite some time.

I hope the Bill passes through the House reasonably quickly and I look forward to working with the Minister and the other members of the Select Committee on Health and Children.

I wish to share my time with Deputy Thomas Pringle.

I thank the Acting Chairman for the opportunity to speak on the Health (Provision of General Practitioner Services) Bill 2011. Once again we are discussing health and health-related issues. Before I go into the details of the legislation, it is important not to duck or dodge the major issues facing our health service. We still have major problems and people suffering because of a lack of real action by successive governments. The reality is that we need reform and investment. The way forward is a universal health service paid for by the taxpayers.

I have heard a number of Ministers and politicians talk about different models in different countries and one regularly hears the Dutch model mentioned. I would like to refer to the Cuban model. Cuba has a fantastic health service and we should look at its ideas, GP services and the excellent health services there.

I hope they are not smoking cigars.

I am told there is no smoking ban in Cuba.

Is the Deputy trying to tell us something?

The last time I was in Cuba there was no smoking ban.

The EU-IMF programme provides for the introduction of legislative changes to remove restrictions to trade and competition in sheltered sectors by the end of the third quarter of 2011. This includes the elimination of restrictions on general practitioners wishing to obtain contracts to treat public patients under the GMS scheme. The contract between the individual GP and the Health Service Executive is based on an agreement concluded between the Minister for Health and the Irish Medical Organisation in 1989. It has been amended on a number of occasions since then and these amendments form part of the agreement.

Under this legislation, the HSE is required, before filling a vacant GMS panel or creating a new panel, to take account of the potential viability of the panel and the viability of existing GP practices in that area. The Bill will open access to GMS contracts to all fully qualified and vocationally trained GPs. There will be no limits on the number of contractors. This is a positive development because it will lead to opening up the services for the people. We must focus on the patient in this debate. We must also remind ourselves that we cannot have a mass exodus of GPs, in particular from disadvantaged areas.

I mentioned the Cuban health service. When I was in Havana I met a young medical student who told me that as part of his training, he was going to work in the villages and in the mountains for three months while the college was closed. This kind of work is very good training for young medical students. I would like to recognise the fantastic contribution Cuban doctors have made in countries like Haiti and in Africa over the past 30 years. They have made a massive contribution to improving health around the world.

In regard to GP services, let us remember that if we have good, effective and efficient GP services, it will reduce some of the problems in our accident and emergency departments. Let us face the reality that we have a crisis in our accident and emergency departments and we still have people on trolleys, which is unacceptable in 2011. Again, it boils down to the beds issue. We need a certain number of extra beds.

That leads us on to the broader debate of tax versus cuts. It is important that those of us who support a health service support a quality and equitable taxation system that pays for the health service. One cannot go around cutting services and expect people not to be on trolleys. Public opinion seems to be in favour of cuts. I think 25% of the population is interested in facing up to the reality that we need to pay for our health service. This must be done through general taxation.

In my constituency, Beaumont Hospital provides excellent services but, at times, it faces major crises in its accident and emergency department. We need to further develop cystic fibrosis services, in particular in Beaumont Hospital. I welcome the fact construction workers are on site at St. Vincent's hospital and I hope the unit there will be completed very quickly.

We need strategies to deal with the GP services but we also need national strategies to deal with the efficient way of running the services. I was absolutely amazed when I read that the fees paid to GPs for administering the ‘flu vaccine were in the region of €42. I welcome yesterday's announcement by the Minister that he has reduced it to €28.50. It is important we cut fees to get value for money and to ensure people get a quality health service.

Another issue which should be dealt with is GP and medical services for people with intellectual disability. We must have more open-minded people and people who are trained specifically to work in this area and act in a very professional manner.

I welcome the opportunity to speak on this Bill, which is very timely and welcome. Everybody in the House will probably support the passage of this Bill. I wondered why we needed the IMF to tell us this needed to be done. It should have been done many years ago to ensure people have a quality health service and a choice available to them in regard to access to GP services.

Deputy Healy referred to rural Ireland and I ask the Minister to consider it. We must provide enticements to ensure GPs set up practices in rural Ireland. There are many advantages to that but it ensures people have a service and a choice available to them.

How easy is it for people to transfer from one doctor to another under the GMS? We must ensure there is a seamless transfer so that medical card patients can move to another doctor if they so wish.

It is vital as this rolls out in the years to come that we have a very worthwhile health service and proper primary care throughout the country with an adequate number of GPs who can provide the cover. Everyone should be entitled to that. It is also important that the Minister ensures the GMS is not abused by GPs. I have come across a number of cases in recent months where GPs have charged medical card patients for the taking of routine blood samples. I note that in the past couple of weeks, the HSE has started to take action in that regard. It is disgraceful as GPs are already well compensated for having medical card patients on their books and are well compensated by the HSE with contributions towards practice nurses, including the provision of insurance cover for them. In many cases, they are provided with facilities, offices and clinics. The HSE must take a very hard line to ensure GPs provide the services to which their patients are entitled and do not add on additional charges which patients can ill afford.

I must ask the Deputy to conclude, as we have reached 7.30 p.m., the agreed adjournment time for this debate. Ten minutes remain in this slot if the Deputy wishes to continue when the debate resumes.

Debate adjourned.
Barr
Roinn