General Practitioner Contractual Reform: Statements

I am pleased to be here this evening to update the House on the outcome of the recently concluded general practitioner, GP, contract talks. I genuinely believe this represents a major step forward in terms of the implementation of Sláintecare, with increased resourcing for primary care and widening the range of healthcare services available in the community.

I acknowledge the important role GPs play in the delivery of our health service and to their commitment to providing a responsive and high-quality service to patients. I am aware that the workload in many GP practices remains very heavy and that the last few years have been particularly challenging.

I recognise also that GPs working in rural and socially deprived areas play a particularly important role in ensuring the availability of health services in their communities. I assure the House that the Government is committed to ensuring that general practice in such areas remains a sustainable and attractive option for doctors. Members will see a number of new initiatives in this new and comprehensive agreement that make that a reality.

The Government, mindful of the difficulties in general practice and in keeping with its commitment to the continued development of GP services, agreed a mandate in 2018 for GP contract talks that would seek to secure agreement on the introduction of new service developments, to include a chronic disease management programme, as well as a suite of reform and modernisation measures. Owing to the range and complexity of the issues to be discussed, the engagement process took a significant amount of time and effort by all parties involved. Following detailed and intensive engagement, the talks finally concluded on 3 April.

The outcome of the process is a comprehensive service development and reform agreement in return for very significant phased increases in funding for general practice for the services provided to medical card and GP visit card patients. This agreement with the IMO is a major milestone for the health service. It provides for a significant package of measures that will benefit patients and also make general practice a more attractive career option for doctors. This is important. We have tried to get the balance right between the introduction of new services and the modernisation agenda, while recognising, as the Chairman of the health committee reminds me regularly, the need to make the existing services sustainable, and recognising that doctors took significant cuts and hits during the financial recessionary years. We have got the balance right in this agreement.

For the first time we will see the delivery of structured care on a large scale for patients with chronic conditions in the primary care setting. Over 400,000 medical card and GP visit card patients with chronic illness, such as diabetes, asthma, COPD and heart disease, will benefit from new and improved chronic disease management. These patients, who would have been seen in the hospital, are now being seen in the community. They are also patients who, through more regular check-ups, can maintain better health with their chronic conditions.

The programme will start in 2020 and will be rolled out to adult patients over a four-year period, starting, appropriately, with those aged over 75. Patients with an existing diagnosis of one of the specified conditions, those who are assessed by their GP on an opportunistic case-finding basis, in addition to those identified as high risk, will benefit under the new programme.

GPs will be paid to provide services for patients with haemochromatosis, which will mean some 8,000 with this condition will no longer have to attend their hospital for therapeutic phlebotomy but can be managed locally by their GP. This could save patients up to three visits a year to the hospital and will also free up very significant resources in the hospital setting.

It has been agreed to pay GPs a fee for participation in weekly virtual consultations with consultant cardiologists to discuss patients with heart failure and agree or amend care plans for these patients. This is a really good example of using technology and integrated care, and of hospital doctors and GPs working together to discuss cases. These virtual clinics will divert patients from acute settings and outpatient department waiting lists. A pilot currently in operation in the Carlow-Kilkenny area has shown a 95% decrease in referral for admission and an 87% decrease in referral to outpatient departments of these patients. The clinics clearly work. The pilot will be extended, and a further three clinics will be established, with four in place over 2019 to 2022. This will provide 17,500 virtual clinic slots per year when fully implemented during which one or more patients will be discussed.

I welcome the agreement by GPs to co-operate with waiting list validation exercises. This will ensure more accurate and current waiting lists, improved access to services and better outcomes for patients.

A wide-ranging set of important modernisation measures has also been agreed in the areas of ehealth, medicines management and multidisciplinary working, as well as the increased use of diagnostic imaging and laboratory services.

Over the next four years, patients, GPs and the health service as a whole will significantly benefit from these initiatives. I particularly welcome GPs’ agreement to engage strongly with the exciting ehealth agenda, another key Sláintecare initiative, which will enable safer, joined-up patient care and will also help the health service to greatly reduce the use of outmoded paper-based communications and record-keeping. We need to move beyond the paper file to electronic health records.

Over the next number of years, GPs will engage in a wide range of important ehealth initiatives, including the rolling out of electronic prescribing, which will enhance the safety and quality of the prescribing process; and the development of summary and shared care electronic patient records, which will give GPs and other healthcare professionals access to important patient information.

The introduction in 2019 of a system of HSE pharmacist-led medication reviews, initially for patients over 75, will facilitate safer, more appropriate and more cost-effective prescribing. GPs will also for the first time formally co-operate with HSE multidisciplinary networks of health professionals, again key to the delivery of Sláintecare.

In return for all this, the Government will increase investment in general practice by approximately 40%, or €210 million, over the next four years. This will see very significant increases in capitation fees for GPs who sign up to participate in the reform programme and the introduction of new fees and subsidies for additional services, such as chronic disease management. Very important, we will also increase support for rural practices and for those in disadvantaged urban areas. The rural practice allowance will be increased by 10% in 2020 and, for the first time ever, targeted funding of €2 million annually will be set aside to provide additional support to practices in deprived urban areas. This is an important development.

Crucially, we will introduce improved family-friendly arrangements for GPs, increasing the maternity and paternity cover for GPs to try to help make general practice a more attractive career option.

I will be sharing my time with Deputy Aylward.

It is good to get the detail but I find this exercise very frustrating. The outline of the deal was agreed about two weeks ago. The GPs have not seen it, the public have not seen it, and we have not seen it. We are being given pages of facts and figures now. We have not seen them before. I have asked the Department for them and I have asked the HSE. We have been denied access to any of the detail. We are sort of expected to stand up here now and respond.

The Members present are the health spokespeople, by and large, and they should have had the information ahead of time so they could give a reasoned response. I am not accusing the Minister - I have no evidence - but this is controlling the message. We should have had this information days in advance. In fact, we should have had it the day after it was agreed with the IMO.

There are parts that I welcome but it is important to state this is not a new GP contract. It is being sold very much as a new one but it is not. There is an important new GP contract to be had and it is very ambitious and very different. It would reflect a genuine new world of integrated healthcare, care pathways and GP-led primary care.

What we have here is some upgrading of the existing contracts, and some of that is welcome, but that is all it is. The reversal of the financial emergency measures in the public interest, FEMPI, is welcome. It was one of Fianna Fáil's core demands in last year's budget, but four years is too long. General practice is on its knees and I would have preferred that it be done in two years, or three years at maximum.

Free GP care for children under 12 years has a whiff of a pre-election stunt about it. Sláintecare does not say that healthcare should be free, it says it should be universally accessible. That is not defined as free but as access to the healthcare that is necessary without incurring undue financial hardship. I have received replies to parliamentary questions from the Minister in the last few days. I asked how many children this will apply to and the answer was "We don't know" and I asked how much it would cost and the answer was "We don't know". There are no costings and no numbers. That really worries me. The offer of free GP care for children under six years was not properly thought through or executed and it caused a lot of problems.

The proposals on chronic disease management are welcome. It is one part of the agreement I really welcome, and it is moving in the right direction, although some of the numbers are wrong. My concern is not about chronic disease management in the community - that is exactly what should happen - but rather the ability of this Government to implement what is necessary. It is a start which we welcome within reason. We will need a much longer debate on this when we have had time to go through the detail.

Rural communities across Ireland are suffering from a deficit of GPs. This trend has worsened over time as more and more established GPs retire. Recently, in my constituency, two GPs, one in Thomastown, County Kilkenny, and one in Carlow town, were due to retire. Both practices provided crucial step-down care support to older people on discharge from St. Columba's Hospital, Thomastown, and Sacred Heart Hospital, Carlow. Several of their GP colleagues around the constituency contacted me to express their great concern that it would be very difficult to replace these doctors who are so crucial to their local communities. The doctors I have spoken to feel the recruitment and advertising methods being implemented are not effective. It must be closely examined and addressed.

We are not doing enough to incentivise young doctors to take up medical practice in this country, especially in rural areas. We cannot allow a situation to arise where rural communities across the country are left without any access to local GPs. While I remain hopeful that the €210 million announced for investment in general practice will entice some doctors to stay, I do not think that it will go far enough to address the systemic problems. It is proving impossible to recruit GPs to certain rural areas due to increased operating costs and dramatic cuts to the grants used to support surgeries. I am calling on the Government to immediately re-examine the supports available to GPs who seek to start up surgeries. In May 2015, almost four years ago, more than one third of GPs in Carlow were aged over 60 years, and they will be eligible to retire in the next year or so. I am sure this is mirrored in many parts of the country. It highlights the need for urgent and radical action.

The agreement reached between the Government and the Irish Medical Organisation earlier this month is a start but its impact on GP waiting time remains to be seen. A constituent came into my office recently. She moved from north Kilkenny to south Kilkenny recently. When her GP took leave of absence for health reasons, an older, retired doctor took over. He said he could not continue to provide her with a service. She tried in Thomastown, with two doctors, and in my parish of Ballyhale, but none of the doctors could take her on. She is a medical card holder but at the moment she has no doctor to look after her. This is serious. It is something that is happening in rural Ireland. If we do not retain the doctors we are training, and put an end to the newly qualified professionals travelling out of the country so that they can provide a service, rural Ireland will have no doctors. That is a serious situation.

I welcome the opportunity to speak. This is a deal that was done two weeks ago, so it is unfortunate that I did not have more detail in advance of the debate. I hope in his concluding remarks that the Minister will commit to a longer debate once we have had the opportunity to digest the contents of the agreement.

We all know the benefits of primary care. It is a low cost, local service. It is good at delivering preventative, quality care much faster and closer to home than alternatives. I wish to pay tribute not only to those on the union side who negotiated the agreement but also to the officials in the Minister's Department. From experience, I know that much work and many man and woman hours go into getting things like this over the line. The Minister gets to make the announcement but the people in the background do a fair amount of the work and that should be acknowledged.

I am not looking at a new GP contract, however, but merely a revision of the existing contract. We are here to talk about the GP contract negotiations but when will we see a new comprehensive GP contract fit for the 21st century and agreeable to all doctors working in general practice? Some of the areas under discussion in relation to improvements to the current contract and the possible inclusion of the chronic disease management will be welcomed. We wholly welcome that approach which makes complete sense. It is regrettable it was not done earlier but we welcome its inclusion now. However, we must acknowledge that the health service has fallen down in the area of chronic disease management. Far too much takes place in hospital and not enough in GP surgeries. It will take a huge effort on the part of general practitioners and they will need support to ensure that they can deliver. To that end, there must be extensive and ongoing engagement with general practitioners and their representatives to ensure that the chronic disease management section is rolled out and that it is done in a way that benefits patients and enhances primary care.

If I missed it, I apologise, but something which seems absent from the agreement is a women's health programme. The Government's failure to include a substantial women's health programme is regrettable. Much more could have been done to restore the trust of women in our health service and, more importantly, to improve health outcomes for women. In spite of improvements in health service provision for women, we see an area where inequalities are stark. I do not need to tell the Minister that if a woman has the money to pay, she can get the results of her smear test back in a couple of weeks, however if she is unfortunate enough to be a public patient, she will wait for 33 weeks. The Government's failure to fully resource and implement the maternity strategy represents a lack of urgency around issues of women's health.

While I am on the subject, where is the legislation on exclusion zones? All the marvellous GPs in the world will make no difference if women are intimidated on the doorsteps of general practices. When I asked the Taoiseach this morning if he had any idea when this legislation would be available, he said he did not know. That did not fill me with confidence. Maybe the Minister can answer that.

This is the revision of the old contract. Any new contract must look at the area of nursing homes and the provision of GP services to residential care facilities. It is a very pressing matter which has been raised with myself and, no doubt, others. It is not something that is going to go away, if anything the need for it will become even more pressing. This essential service needs to be enhanced. It is provided in many nursing homes on an ad hoc basis. Sometimes it is provided by the grace of the general practitioner, usually related to a personal relationship between the staff and the nursing home, and that is not good enough.

I will get on my hobby horse for a moment as there is no mention of additional physical infrastructure. For instance, in Balbriggan, in my constituency, there is a beautiful primary care centre. It is absolutely gorgeous and it is stunning but all it is is a glorified GP surgery.

There are no scanners or diagnostic equipment in the centre. I put a parliamentary question to the Minister and the response I received is that he is not considering enhancing the equipment or the facilities available in Balbriggan at this time. That is contrary to what his colleagues say in the constituency but it chimes true with me because we see no evidence of any plans in the pipeline.

Finally, there is a real need to look at the issue of salaried GPs. Directly employing GPs will allow doctors to be doctors and they will not have to worry about renting, being employers or any of that. We need to examine how the dual model will work. The small business model has worked well - I do not dispute that - but I believe that directly-employed, salaried GPs have a role to play. There is space for a dual model. When we have our longer and more in-depth debate, hopefully we will be able to tease out those issues.

In fairness, I do not want to rain on the Minister's parade. He has enough issues with which to deal.

I do not know why we are having this debate tonight. It would have been time enough to have it at a later date because the information is only coming through. We are having to analysis it and go through it now. I would like to have had time to talk to many of the GPs who I have worked with over the years to go through some of this.

In fairness, the Minister and his colleagues have put a great deal of effort into this. I respect that. I welcome a significant amount of what is proposed. All the measures relating to doctors, such as the family-friendly measures, etc., will make the profession more appealing to those who want to remain in it. The measures to address the number of GPs who leave the country - a matter not dealt with to date - are all welcome. As somebody who was a member of the Government that introduced free GP care for children, I welcome that it is being extended to those under 12. However, this is the outline of a deal. We do not know fully how it will be received or how it will be implemented. For example, on the aspect of extending free GP care to those under 12, there is another negotiation that has to go on and then individual GPs will have to decide whether they will participate or not. The process by which that will happen all needs to be worked out.

I do not have enough time to go into the detail of all the individual issues. Following the process the Minister went through with this, I presume there is an estimate of the real impact what is proposed will have on retaining GPs in this country and also on enticing more to remain in the profession. Is he in a position to put figures on the estimate of the impact it will have in that regard? In other words, how are we to arrest the decline and does the Minister have the type of estimates to which I refer?

I specifically want to discuss GPs in rural Ireland. We have a particular problem in geographically isolated areas. Given that the Government, which does not have long left in office, is intent on implementing Project Ireland 2040, there will be fewer people living in rural areas. As a result, GP contracts in those areas will be less viable. I have no doubt that the Minister will have to resort to a different direct-employee contract for GPs in isolated rural areas. Has that been dealt with? Will that form part of this agreement? Has it been considered? What is the status of that? We must have that. I can categorically guarantee that unless the Minister has that type of contract in certain specific geographical areas, there will not be GPs there. I can tell the Minister that right here. That is the direction in which Ireland is moving; that is the trend. That is where the Government is going with Project Ireland 2040.

Something the Minister cannot throw back at me is ehealth. I speak about this all the time. Few Members have come in here and spoken about this at length as I, coming from that background myself, have done. I read a great deal here about ehealth, e-prescribing and a range of other matters. I actually do not know what these terms mean. Where are they in relation to the public service card? Where are they in relation to the ehealth card? Where are they as regards the data? What will be the process? What infrastructure has to be put in place? What pathways are there for the sharing of information? How will all this work?

I agree with ehealth. Is there a guarantee of consistency? Is there a guarantee that all GPs will participate because when one moves across to such new measures, one must ensure that everyone is on board. One cannot have a situation where some GPs are participating in a new way of doing things and others are not. If one leaves in that scenario, and patients change and GPs change, with different health systems all of that must apply across the board. Can the Minister give us a guarantee in his reply that it will apply across the board? I know by the Minister's demeanour that he is not sure. I would really appreciate knowing. That would be a significant issue.

In the context of ehealth, will analysis of referrals from GPs be supplied into the central system of the HSE? For example, there are serious issues in the mid-west regarding referrals to hospitals. Some GPs practice fantastically not a large amount of referrals. Some others who have a significant amount of referrals do not. I am not saying every area is the same. One is not comparing apples with apples and oranges with oranges. In general, however, there should be some form of trend. I hope that data is being gathered as part of this process as it all would help us.

Without going into the individual components of what we understand to be agreed, there is one final matter about which I am disappointed. I would like to see some emphasis on the GP role in advocacy as regards future screening programmes. If the Minister could stitch that in, I would welcome it. It would not be a major issue. I would take it as a positive if the Minister could go back and look at ensuring that an advocacy role, for all the reasons that we have debated previously in this Chamber, is included in the eventual contract. That would be a welcome development.

The current GP contract is 47 years old. There have been no major structural changes to it in that time, bar a little tinkering.

General practice in Ireland receives 3% of the overall health budget and yet general practice in most developed countries receives 10%. This disparity needs to be addressed in Ireland. Research has repeatedly shown that if one spends €1 on investment in general practice, one will save €5 at hospital level. Seven hundred GPs are due to retire in the next five years in Ireland. Some 70% of GP practices outside of Dublin are closed to new patients. Where are these patients supposed to go? Only 20% of GPs are IMO members, 40% are members of the National Association of General Practitioners, NAGP, while 40% are not members of any union. This new contract has been negotiated without the input of the vast majority of GPs or their representative bodies. The vast majority of GPs have still not seen the new GP contract. Only one-in-five GPs have seen the contract via the IMO.

The proposals relating to reversing FEMPI cuts - amounting to €120 million over three and a half years - will not save general practice. The reversal package is grossly underestimated in terms of what is needed according to the GPs to whom I have spoken. The three-and-a-half year timeframe is far too long.

GPs in Wexford are adamant that for general practice to survive in the county and, indeed, nationally, particularly in rural areas, the following need to happen. First, there needs to be serious acceleration in the context of reversing FEMPI. Second, GPs need an optional out-of-hours commitment. Fifteen years ago, the NHS made out-of-hours optional. This agreement was signed by more than 95% of UK GPs. It has been a success, despite initial British Government fears. The sky did not fall in by giving GPs flexibility in terms of working out of hours. It is nuts for there to be 24-7, 365-days-per-year commitments for GPs. This kind of unreasonable burden for GPs is doing nothing to attract young doctors to the practice. Another vital requirement is a new GP contract. GPs need flexible contracts that are family-friendly. That is crucial. Of course, capitation needs to be increased but flexibility must also be built in to the new contract.

The GPs to whom I have spoken are deeply concerned that after all this time waiting for a new contract, what they are actually getting is not really a new contract at all but, rather, a slow, drawn-out reversal of FEMPI. GPs fear that they will be simply returning to a pre-FEMPI state, that they will be back to square one and that they will not have made much progress.

I am only telling the Minister what I am hearing from GPs, I am no expert on medicine.

There is a perception that GPs are rolling in money but, for those on the existing contract, that is far from true. More than 50% of the population has access to free GP care. For example, the fee through the GMS contract for female patients aged 16 to 45 is currently set at €43.79. That fee is per year, not per visit. That is how much Irish GPs are paid for unlimited, 24-hour access, seven days per week, 365 days per year for this group. Ireland is haemorrhaging GPs and cannot attract new people. I spoke to a GP in Wexford town, Dr. Bill Lynch, who had to go to Barcelona in order to try to hire new GPs. A realistic, flexible, indicative staff budget must be agreed. What about sick pay, maternity and annual leave?

I hope that the new contract will clarify the issue of GPs charging for routine blood tests, a practice that is clearly prohibited under the Health Acts. The Minister has repeatedly stated that the GP contractual review will provide clarity on this decades old problem. I am regularly contacted by people who are incorrectly charged for blood tests. I have sympathy with GPs who are so financially squeezed that they are leaving general practice in droves but the situation has, for many patients, created a toxic relationship with some of their GPs. It has caused a significant amount of stress and financial difficulty for patients in Wexford and elsewhere.

Perhaps the Minister can explain why patients I have spoken to must wait for a year and a half to get refunds in respect of charges which never should have been imposed in the first instance. Some people do not even know their rights when it comes to charges or accessing refunds. Even if they do, the inconvenience and delays involved in getting refunds is infuriating for many individuals. If we are not going to enforce the existing legislation and provisions of the existing GMS contract, can we at least have a fit-for-purpose refund scheme? A very obvious solution to this problem would be to actually recognise the workload GPs do and their importance to communities in delivering primary care services and to properly reward them for this service with the kinds of contracts they deserve.

The Minister stated that he recognises that GPs working in rural and socially deprived areas play a particularly important role and that he wishes to assure the House that the Government is committed to ensuring that general practice in such areas remains a sustainable and attractive option for doctors. It is not a sustainable and attractive option for doctors right now so for the Minister to say that he wants it to remain so is playing with language. The majority of GPs I encounter in Wexford indicate that it is not a sustainable and attractive option. Can we make it sustainable and attractive? Failing to do so makes no sense.

I thank the Minister for introducing this topic. We have had many conversations about the issue and I welcome the proposed agreement between the IMO, the Department of Health and the HSE which is still under discussion at IMO meetings. I may have an advantage, being an IMO member, in that I have in my possession a document which outlines, in broad brush strokes, what is contained in the agreement.

I welcome the agreement because it will reverse the cuts that were introduced by means of the FEMPI legislation. I also welcome the fact that it starts to integrate chronic care between primary and secondary care, to digitally gather information about population health and hopefully it will start ehealth initiatives, such as e-prescribing, which have tremendous advantages in general practice. This is a reversal of the disproportionate application of FEMPI to general practice. FEMPI made many practices financially unsustainable and led to the disbandment of many practices in urban and rural areas, practices which no longer exist. It has led to the loss of full-time GP services in many areas where practices have been amalgamated with practices in the nearest town. FEMPI has created a vacuum which has allowed to enter general practice commercial entities that may not have the same vocational value as existing general practices. It has also allowed gaps in the system where pop-up GP practices are now appearing in many urban areas which do not supply the same quality of care that established general practices do.

FEMPI has led to the manpower crisis we currently face. Some 70% of practices are not taking on new patients. In many towns and some counties, there are no GPs who are taking on new patients and that is because of the workload that has developed on foot of the manpower crisis. Only 90 GPs under the age of 35 hold the GMS contract and 700 GPs are due to retire over the next decade. There is a real manpower crisis and we need to start training more GPs if we are going to deliver the enhanced services that this agreement proposes and to give free additional care to the first cohort of patients, those under the age of 12. The Minister must understand that under-12s are not the most needy cohort of patients in our community. It is political policy of Fine Gael but healthcare should be delivered to the most needy. That is a policy issue over which we, as GPs, have no influence.

A GP visit card facilitates a free visit to a GP but it does not carry the other services that a full GP card delivers. That is a major fault in only supplying GP visit cards because it disenfranchises people who are expecting to get a full service and who do not.

We need additional GPs to deliver chronic care which is already devolving from our hospitals. This contract copper-fastens what many of us are doing. Some 53% of doctors who left the Medical Council in the past number of years are aged under 35 and many of those are newly-qualified GP trainees who do not see a future for themselves in Ireland. It is in this context that the agreement has been reached. I welcome the agreement because I hope it will reverse some of the trends that I have just mentioned. I hope it will lead to a reversal of the loss of GPs from our general practices and only time will tell.

This is not a new GP contract, it is reform of the existing contract. It appears that a new GP contract is at least four years away, particularly if we are to carry through the reforms outlined in this document. Nevertheless, I welcome the restoration of funding and it is important that it is front-loaded. Some 50% of the restoration of funding will come on 1 July and that is important because it will give hope to practices which are struggling financially. It will allow practices to employ staff, I hope, and also to supply a wider range of services.

The agreement is a tangible first step in implementing Sláintecare. It is the very first tangible step that patients will recognise that Sláintecare is beginning to be rolled out. It reorients the health service back towards primary care. It places general practice at the centre of health reform and starts to develop chronic disease management in general practice but this will only pay dividends if that is integrated with our hospital service. It must be an integration of chronic care between primary and secondary care to get the maximum value.

It is very important that GPs' co-operation with community health networks is from the bottom up and not the top down. GPs need to be involved in organising, financing and making decisions about how resources are dispersed throughout their population in their community health network and the advisory council that has been set up and the implementation office, under Ms Laura Magahy, will be crucially important in ensuring we get this correct. It should not be a diktat but should come, rather, from the bottom up, where GPs are equal to all the other stakeholders in that process.

I welcome the roll-out of ehealth over the next four years. In particular, e-prescribing is the initiative on which the Government should concentrate.

There are many points I would like to discuss but the deprivation fund set up for, most likely, inner city practices is extremely important. The Minister has probably heard from Deep End Ireland how critically important health needs in deprived areas are and how they are not funded properly. This fund is innovative and I welcome it.

I will echo the points made by previous speakers. There was not much consideration given to other Members in providing the detail of this deal. The relevant information should have been provided some time ago, and long before this debate.

That was quite disrespectful to Members on this side of the House.

It is 18 years since the primary care strategy was launched. In that time, no Government or Minister for Health has been serious about the primary care strategy. Mere lip service has been paid to it, which is quite incredible when one thinks about the primary care strategy of 2001 and several subsequent related strategies culminating in the Sláintecare report. The reorientation of the health service away from expensive acute hospital care to community, primary and social care is not rocket science but, rather, very basic logic about the right way to run a health service. It makes absolute sense to have early intervention regarding medical conditions and for services to be provided locally at the lowest level of complexity and close to where the patient lives. That is the way to get the best health outcomes and, of course, the best value for money. However, for some unknown reason, no Minister has given effect to the aspirations in the primary care strategy. That may have been due to a lack of courage on the part of the many Ministers over the past 18 years because most of the vested interests are located in secondary care. There are some very strong vested interests in that area. We know that the hospital sector has always taken the lion's share of health funding and, for that reason, we have a very skewed, inefficient and ineffective health system. Regrettably, no Minister was prepared to reorientate the health service to where it ought to be and tell the hospital sector and the various vested interests that this was not the right way to run a health service and that we were going to emphasise and prioritise primary care. Unfortunately, that has not yet happened. I very much welcome the fact that the Sláintecare report is so strong on the need to reorientate the health service. There is a clear blueprint for doing so and, as such, there is no excuse for the Minister or any of his successors not to act in that regard. It makes absolute sense to so do.

My concern is that there is a 47 year old contract which has not been fit for purpose for some time. Even after this deal, it will remain unfit for purpose. There is no doubt that the deal contains improvements, but it is not a new contract. We cannot run a modern health service on a contract that is almost 50 years old. Although several elements of the deal are to be welcomed, the reality is that an entirely new contract was needed. I very much regret that after all of the promises and early days talks and so on, the Government came up with a deal which only tinkers with the original contract. There is an acceptance of that fact on the part of the Minister, who stated that there is a need for a longer-term strategic review of how general practice should operate within the health service and that the Department will lead a strategic review of general practice with a view to developing a new contractual framework. There has been 47 years in which to do that. Why is it that at this stage, after all the protracted talks, the Government is only now recognising the need for a strategic review? God knows when we will see an outcome from such a review. It is very disappointing that there is no new GP contract, which is what is needed.

That said, I hope that the Minister moves quickly and that this is not the end of what he will deliver in regard to contractual arrangements with GPs but, rather, is only the start. I hope that he is serious about the strategic review and that it will get under way very quickly. I remind the Minister that the Committee on the Future of Healthcare, which examined this whole area in significant detail over a long period, wrote to him and outlined several key areas that needed to be included in a new contract. These issues arose time and again in the course of the Sláintecare process. Key things that are currently missing are the issue of access to diagnostics, the need for an ongoing review of the contract - we should not have such a long contract period - and the need for salaried and part-time GPs.

The agreement goes some way towards restoring the savage FEMPI cuts. The individual measures regarding chronic disease management are to be welcomed, as is the €2 million set aside for GPs working in areas of disadvantage in particular. Deep End Ireland is doing an extraordinary job in that regard. However, far more needs to be done. We can achieve far more through our health service if the Minister takes the lead on this issue and takes bold steps in respect of the much-needed reorientation of the health service away from hospitals and towards primary and community care.

I thank Deputies for their contributions. I look forward to a longer debate on this issue at a time of the House's choosing. I assure Deputy Shortall that I am deadly serious when it comes to the reorientation of the health service, as, in fairness, is she.

The real test for the House will be when I begin bringing forward legislation on issues such as geographical alignment. I intend to publish my proposals on geographical alignment before the summer recess and I expect them to be very closely aligned with the report of the Sláintecare committee. Let us then see Deputies put their money where their mouth is. Deputy Shortall is aware how jittery politicians get when one starts drawing lines on maps and when they hear from the vested interests to which she referred. I will return to the House with proposals that will result in massive reform of the HSE, devolve far more authority to the regions and, crucially, integrate the currently ridiculously disparate situation whereby our community health organisations and hospital groups operate as separate entities and, often, separate fiefdoms. It will take several years to get to where we need to be. I will go to Government with my proposals in that regard and publish them in advance of the summer recess.

Several Deputies stated that the agreement is to be welcomed, but that simply restores the cuts. Of course, in many ways it is restoring funding, but an honest analysis of the situation is that it does more than that. FEMPI accounted for approximately €120 million, but this deal is worth €210 million. I recognise that Deputies have welcomed elements of the agreement, if not all of it. The agreement has been very warmly welcomed by many general practitioners, patient advocacy groups and, indeed, the Irish Medical Organisation, which worked very hard on it, as well as the National Association of General Practitioners in its public commentary to date. I join other Deputies in thanking my officials, led by Fergal Goodman and Eugene Lennon, as well as officials in the HSE who put many late nights and an intense amount of work into arriving at this point.

Several Deputies referred to Deep End Ireland. I met its representatives during the Sláintecare process and am aware that the Sláintecare committee also heard from them. They made the point that we have effectively had a rural allowance for many years, which is proper order. That allowance will be increased by 10% next year on foot of this agreement. However, they also pointed out that, recognising that there are also difficulties and deprivation in urban Ireland, we need a dedicated fund in that regard which may be the equivalent of that for rural Ireland and the details of which could be worked out with GPs. The €2 million annual fund will make a difference.

Deputy Harty was honest and fair in his analysis of the situation when he stated that within the agreement is a tangible sign of movement on Sláintecare. The agreement has at its heart the ehealth agenda, without which Sláintecare cannot be delivered. It also focuses significantly on chronic disease management and integrated care. It is very much Sláintecare in action.

Members are aware of the difficulties experienced in general practice. I acknowledge those difficulties and this deal is recognition of them. However, I must also put some facts on the record of the House. The number of GPs on the Medical Council specialist register continues to increase. There were 2,270 GPs registered with the Medical Council in 2010 and 3,729 as of 1 January last.

Why are they not applying for jobs in the system?

Possibly because of the 75% FEMPI cuts which were introduced by Fianna Fáil during its time in government and which I am now reversing. The number of GPs holding GMS contracts has also risen, from more than 2,098 in 2008 to more than 2,500 this year.

If we are to make general practice more sustainable, we need to introduce more family-friendly measures.

That is why this agreement will significantly increase the funding for maternity cover for female GPs and will also increase paternity cover for male GPs from three days, for which they are covered now, to 14 days. When the rural allowance, the urban deprivation fund and the restoration of fees, which will see funding to general practice increase by 40% during the lifetime of this agreement, are coupled with some of these family-friendly measures, I genuinely hope and expect, as do GP organisations, that we will begin to make this a more attractive career. The first point, though, was to try to stabilise general practice. Before we got into introducing a load of new services, it was important to recognise there was a challenge and that GPs had suffered huge cuts during difficult years. It was important to try to stabilise that situation, to use that opportunity to push and work with them on a modernisation and reform agenda in order that they are ready for the delivery of Sláintecare and to provide extra funding for new services. That is what we have achieved. It is a fair and balanced deal. Of course there is more to do, and we have more to clarify in terms of the work we need to do in Sláintecare on the eligibility framework, which is a big body of work we are undertaking this year. I would certainly welcome a longer debate in this House on this matter and indeed questions on the matter. I know the GPs are beginning a process of intense consultation, which took place in Dublin last night. This is a chance for them to discuss what this deal means to them.