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Joint Committee on Health díospóireacht -
Wednesday, 26 Jan 2022

Issues Relating to General Practice: Discussion

I welcome the witnesses to the meeting to discuss issues relating to general practice. From the Irish Medical Organisation, IMO, I welcome Mr. Val Moran, director of industrial relations for general practice, public health and community health, and Dr. Madeleine Ní Dhálaigh and Dr. Tadhg Crowley, members of the IMO general practice committee. From the Irish College of General Practitioners, ICGP, I welcome Dr. Diarmuid Quinlan, medical director, Mr. Fintan Foy, CEO, and Dr. John Farrell, chair of the ICGP board.

Before we hear the opening remarks of the witnesses, I need to point out to them that there is uncertainty as to whether parliamentary privilege will apply to their evidence if given from a location outside the parliamentary precincts of Leinster House. If, therefore, I direct them to cease giving evidence relating to a particular matter, they must respect that direction. All witnesses are reminded of the long-standing parliamentary practice to the effect that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of a person or entity. If, therefore, their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.

I call Mr. Moran to make his opening remarks.

Mr. Val Moran

I thank the Chair and the IMO thanks the committee for the opportunity to discuss the issues facing general practice. No more than many other areas of the health services, general practice has been facing a capacity issue for more than a decade. At the same time, patient demand has increased and, for a large part of the decade, funding has decreased. For many years the IMO, the ICGP, the HSE and the Government have commissioned independent reports that have highlighted the problem with GP numbers and identified the required number of GPs to meet the needs of patients. We have yet to significantly address solutions that will drive change.

Covid has exposed the fragility of our health service but the pandemic did not cause the problems. In the main they were caused by significant cuts to funding during the years of austerity. The budget for general practice was cut by €120 million, and it is only this month that the final phase of restoration is being paid. It is being paid over a period of three years but it is only this month we are getting back to 2008 levels.

Despite the lack of funding, GPs and their teams have continued to care and, more importantly, provided the continuity of care which is associated with better health outcomes, equity of access and more appropriate utilisation of services. Patient satisfaction with the service is still high but we know there are issues with access in some areas where GPs cannot safely take on new patients. There are large parts of the country where the number of GPs is not adequate to meet the needs of an ageing population. Capacity has to be addressed. We have to look at all the factors affecting capacity while at the same time ensure we do not overburden the service.

How many GPs do we have and how many do we need? Approximately 3,500 GPs practice in Ireland. This can be broken down further to 2,500 who hold a General Medical Services, GMS, contract, which is the medical card contract, 500 GPs who hold other publicly funded contracts, such as primary childhood immunisation and maternity and infant care, and a further 500 working outside of publicly funded contracts. This is an average, therefore, of 0.69 GPs per 1,000 population when we require 1.1 GPs per 1,000 population. The distribution of GPs is not uniform. Some areas of the country have a much lower ratio of GP per 1,000 population.

Numerous studies show that the greater the number of GPs per head of population the better the health outcomes, including lower rates of overall causes of mortality. The most recent analysis of medical workforce requirements from national doctors training and planning, NDTP, estimates that an additional 1,260 to 1,660 GPs are needed by 2028 to meet the needs of population growth, in particular the significant growth of those aged over 65 and those aged over 85 who are naturally high users of the service. We have a growing percentage of people in these older age categories and they use the services a lot more and place much greater demands on the service.

What are the issues driving these capacity problems? The demographic trends in general practice no more than the rest of the population are stark. A growing proportion of GPs are over 60 with one fifth due to retire over the coming years. There are high levels of burnout and stress associated with the demands of the service. Many GPs are unable to take sufficient annual leave or appropriate sick leave. A recent IMO survey on mental health and well-being found that 59% of GPs were unable to take time off due to difficulties with sourcing locum cover for annual leave and 66% said they were unable to take sick leave. This is a huge number unable to take sick leave. Two thirds were unable to find a locum to do so. The stress and burnout that comes with this pressure is quite high and contributes to people leaving general practice earlier, which builds the capacity problem. The lower the number of GPs the more difficult it becomes to get a locum. It is almost self-perpetuating.

For young GPs, there is a high risk burden associated with setting up a practice. There are significant start-up costs relating to premises, IT staff, medical equipment and other overheads. The risk burden with setting up in practice initially is huge. A significant financial cost has to be incurred and many younger GPs are not in a position to take on that risk. There is insufficient support for hiring a fully functional GP team. This team includes assistant GPs, practice nurses, healthcare assistants, allied health professionals and administrative staff.

There is increased demand coming through also. There is a lack of referral options to other services in the acute and community setting. This means GPs have to manage patients in the community who are waiting for specialist care. We know that 900,000 people are on some kind of waiting list. These patients require care for their condition while they await specialist treatment. In the large, this has been dealt with in the community. There is no real control over demand unless patient numbers are reduced. We see that GPs are closed to new patients in certain areas because they simply do not have the capacity to meet demand or safely care for those patients. Whatever Government policy is on access to GP services it has to be introduced on the basis of sufficient capacity and appropriate supports and funding.

There are potential solutions and I will outline a few of them briefly. A key point for us is supporting and establishing GPs. Earlier I spoke about the risk burden. We have to acknowledge the factors that are an obstacle to establishing practices and develop a model that will allow GPs to start off their careers and support them in this. We seek an enhanced range of supports including but not exclusively tax relief to assist in the funding of premises for critical equipment, infrastructural equipment including IT systems and medical equipment. A number of years ago, an Indecon report recommended tax incentives in this manner and we fully support this recommendation. We call for partnership pathway support funding to allow an existing GP to take on an assistant, who would then enter into a succession arrangement with the GP to take over the practice over a number of years on a phased basis.

The GP may be close to retirement. Rather than the list being advertised and nobody applying for it or an issue arising with succession, the GP is able to have an assistant for a number of years who will then take over that practice.

We need to broaden the GP practice team. Supports are available at the moment. There is a practice nurse and practice subsidy support for GPs in the GMS. These were established in the late 1980s or early 1990s. General practice has moved on a lot since then. Additional staff, for example, healthcare assistant grades and allied health professionals, could be taken or a GP may want to have access to physiotherapy, counselling and pharmacy supports within the practice. There is a need to broaden the supports available in terms of practice subsidies.

Regarding the workload and structure programmes for delivery of healthcare in general practice, we should certainly be looking at defined models of care. The chronic disease model has been a great success. To meet the needs of large cohorts of patients in a structured and proactive manner, it is critical that we expand this programme and that other structured programmes are introduced. The area of women's health, which has long been neglected by the State, is a priority for us. We believe a structured programme dealing with reproductive health, including contraception, maternity care and menopause, should be developed in general practice. Fragmented care is not good for the patient, taxpayer or service.

The out-of-hours commitments are also a significant barrier to people entering into general practice. GPs effectively have to fund the cover provided to patients outside of normal daytime hours. They do this by doing shifts themselves and paying locums for red-eye shifts. This is a factor for people going to certain areas in that the area may have an onerous out-of-hours rota in place. The system has evolved from the initial requirement, which was to provide access to urgent care outside of normal hours, to a routine service outside of normal hours. A national review is required to ensure it is not an onerous burden for GPs, it is equitable across the country and that the model provides safe access to urgent care.

Tied into that, there is an issue with locums, which has long been flagged. I talked about being unable to take sick leave and annual leave. That is obviously not safe. It is not desirable for GPs to work beyond capacity and it obviously deters people from taking up practice in their own right when they are unable to take leave. Responsibility for sourcing and funding locum cover currently lies solely with the GP. Given the huge difficulties and costs associated with this for the GP, the HSE needs to take a much more active role, where necessary, by securing locum cover in certain instances and ensuring that GPs can take leave.

General practice is a rewarding career. However, if we wish to make it attractive to the next generation of doctors and ensure the ongoing delivery of high-quality GP care to patients in their communities, we must address these capacity issues now. We have talked for more than a decade about these problems. We have produced endless reports. There is no single quick fix. A suite of measures needs to be taken and addressing the problem will require significant and ongoing funding. The time to plan and invest was probably ten years ago but the next best time is now. I thank members for their time. We will be happy to address any questions they may have.

I thank Mr. Moran for his opening remarks. I call Dr. Quinlan.

Dr. Diarmuid Quinlan

I thank the committee for extending this invitation to the Irish College of General Practitioners. My colleagues, Dr. John Farrell, chairman of the board, and Mr. Fintan Foy, CEO, are here also. It gives me great pleasure to address the committee this morning. I propose to align my presentation with an overarching proposal, namely, to establish a working group on the future of general practice that would look at the key challenges of the GP workforce and workload. I will also discuss some challenges and practical proposals.

The Irish College of General Practitioners is the professional body for general practice in Ireland. As Mr. Moran said, we have approximately 3,500 GPs in Ireland and approximately 850 GP trainees. General practice is fundamental to delivering timely, equitable access to high-quality healthcare across Ireland. The international evidence is very clear. Healthcare systems with strong primary care have better, more equitable population health outcomes and are more cost-effective. One key factor is that one extra GP per 10,000 of population reduces hospital referrals and hospital admissions.

The overarching strategy we would propose is to establish a working group on the future role of GPs in the provision of community healthcare. This will require engagement of the key stakeholders, namely, Government, the HSE, the Department of Health, the ICGP, the IMO, the Irish Medical Council, IMC, and patient representatives. General practice essentially needs a much expanded workforce with the appropriate skill mix, high-quality purpose-built premises and administrative and IT supports to ensure we can deliver high-quality accessible care for patients right across this country. This will require substantial and sustained investment.

Our 2021 and 2022 pre-budget submission called for the establishment of a working group on the future of general practice. Unfortunately, this group has not yet been established. However, we are hopeful the committee would support such a proposal and we encourage it to do so. This high-level working group would work with the key stakeholders to plan and develop the immediate and sustained expansion of general practice in the community.

I will next address the workforce challenges we face. There are multiple challenges and many factors underlying the current unprecedented workforce crisis we face. The ICGP has long voiced that we need a sustained and substantial State investment to meet needs. As Mr. Moran said, the HSE predicts a shortage of at least 1,000, and possibly in excess of 1,660, GPs by 2028. Underlying this is the fact that our population is growing and recently exceeded 5 million people. We have a substantial and welcome increase in people aged over 65 and will have almost a doubling of people aged 85 and over by 2025. While this is really welcome and shows that we are providing very good care to our older patients, it also increases healthcare utilisation. In 2018, the HSE identified that we need an increase of almost 50% in the primary care workforce by 2025, which is only three years away.

General practice is pivotal in delivering healthcare. GPs provide in excess of 29 million consultations in daytime each year and well in excess of 1 million consultations in GP out-of-hours services. General practice has been fundamental in supporting the national response to the Covid-19 pandemic by delivering more than half of the Covid booster vaccinations, which was a key component in keeping society safe and enabling the reopening of our society.

I will now address the challenges that our general practice workforce faces and then outline some very practical solutions. In a nutshell, we have 30% fewer GPs per head of population than England. We have a substantial and long-standing workforce deficit. The Department of Health in 2018 recommended an increase of almost 50% in GP numbers. We have an ageing GP workforce. One in seven, or 14%, of our GPs is aged 65 and over. I anticipate that the majority of these will retire in the next three years. This is coming rapidly upon us.

Approximately one quarter of our GPs are in single-handed practice, especially in rural areas, which presents its own challenges for people living in villages across Ireland. We have insufficient primary care teams, nurses, phlebotomists, healthcare assistants and pharmacists. The workload of general practice is expanding substantially as we have an ageing and frail population with multimorbidity and polypharmacy. We have the capacity and ability in general practice to care for these people but we need more GPs. We also know that increasing GMS eligibility predictably increases GP workload and while it is welcome that people can access their GP more readily, increasing the demand on a constrained service is sometimes counterproductive. The Covid-19 pandemic exposed the fragility of all our health service and, most especially, general practice.

I will now address the components of the solutions we propose. The first of these is the fundamental need for a substantial increase in GPs. We need to train more GPs and the HSE is supporting the ICGP in doing that. The good news is that in 2015, we had 159 GP trainees. By 2021, it was 236, by 2022 it was 258 and by 2026, we anticipate having 350 GP trainees. It brings its own challenges to achieve that but the process is certainly well under way.

We also need to put in place incentives to motivate young GPs to establish in general practice, retain mid-career GPs and support our older GPs to continue in practice. Part of this involves looking at the entire streamline. The development of interns in general practice is necessary. We need a substantial increase in the number of training places in hospitals because general practice is a four-year training programme. That programme has moved into the ICGP but it is a four-year programme. We need to increase the number of training posts in hospitals to allow GPs to train because we do two years in hospital rotations and then two years in general practice. One of the bottlenecks is identifying suitable training posts in hospitals for our young GP trainees.

We also need to recruit GPs to work in rural areas. There are many barriers to GPs working in rural areas, particularly the onerous out-of-hours rotas, incentives to make it financially possible for them to do so, guaranteed locum provision, suitable premises and out-of-hours commitments.

These are all real barriers. Other countries have done this with success. We have a very large rural population and the largest percentage of people living in rural areas across Europe.

Almost half of our practices comprise one or two GPs and these need specific incentives to make these sustainable in the longer term. This will include built infrastructure, shared delivery of services, and a shared network of supports, including staffing, locums and nursing support. We need to look beyond our own shores and support non-EU GP recruitment. Non-EU GPs can now apply for training in Ireland and we must accelerate this and support relocation and integration of appropriately qualified non-EU doctors. This is a short-term response to the current severe deficit but we must provide structural and highly supported entry into Irish general practice. This is currently under way in part supported by the HSE.

We have a major shortage of GP nurses in Ireland. Our GP nurses are highly skilled autonomous clinicians and they have a very broad and deep clinical expertise. To give an example, in my practice in Cork we have eight GPs but just one whole-time equivalent nurse. A similar-sized practice in the NHS would have between six and ten nurses and, therefore, we need substantially more GP nurses. We need to look at the career, development and professional structures to enable more nurses to enter general practice and provide them with a career pathway for advanced nurse practitioners, nurse prescribers and clinical nurse specialists to support the fantastic chronic disease management programme that we have. Other countries have done this and NHS Scotland has done a similar programme with great success. We also need far more allied healthcare assistants in addition to nurses and other professionals working with us in general practice.

There is a major paucity of data in general practice. The HSE ICGP Sláintecare research hub is rapidly addressing this strategic deficit. Irish general practice is almost entirely computerised and this will provide us with real-time data. We are seeking a cohort of funded GP-centred practices to provide data on the quantity, quality and quantum of GP activity.

The final matter I want to raise concerns built infrastructure. As Mr. Moran said, this provides a major barrier to young GPs coming into general practice. Society does not expect other healthcare workers to provide their work premises and the bricks and mortar is perceived by many young GPs as a barrier to recruitment, retention, mobility and, ultimately, their retirement. Other countries, including Scotland, have addressed this. We call for innovative solutions and we are certainly open to discussing them. As we expand our GP team, we will need substantially more clinical space, with associated infrastructure costs.

To conclude, we have an overarching proposal, which is the establishment of a working group on the future of general practice in primary care in the community in Ireland. This working group will address the workforce and workload challenges I have touched on, including the very substantial shortage of GPs, GP nurses and allied healthcare professionals. We must look at our data and address infrastructure. I thank the committee for the opportunity to raise these matters and I look forward to its questions.

We have slots of ten minutes for questions and answers. Senator Kyne is first.

I welcome the representatives from the IMO and ICGP. I acknowledge the role played by GPs during the Covid-19 pandemic, although it is still sort of with us. They provided a service to patients and administered the vaccine and booster campaign.

There is always a view that there are issues with regard to rural versus urban cover of GPs. There was a campaign entitled No Doctor, No Village run over a number of years with the argument that rural areas are suffering. We also hear that in urban areas there are pressures from GPs not being able to take on more patients, see them or provide appointments for a number of days. What are the obstacles in front of a new graduate who wants to become established in an area of growing population and there is an evident need for additional GP services? What, effectively, are the obstacles to graduates coming out after being trained and who want to establish a practice?

Dr. Tadhg Crowley

A new graduate coming out is establishing a business so in the first instance, trying to find a property or premises can be a huge cost before setting up at all. There is also the question of infrastructure, such as computers and various equipment that we now consider normal in general practice. Along with that a GP must employ staff, including secretaries, receptionists and practice managers to make the operation as efficient as possible before starting at all. Patients need to come in the door as well. Starting on day one, without ever having met patients or being known in the locality, it takes time to build up that relationship. At the start, banks certainly are not as forgiving as they may have been 40 or 50 years ago. They are looking for repayments on the loans from the very start. It can be a huge stressor before even starting. In the modern environment, many students are starting with loans before they even open in general practice.

Has the rolling out of primary care medical centres assisted in addressing some of the issues? At least that would be a base from which to start. Has that been of assistance or is it a case that many buildings are not fully utilised because there was not the buy-in with GPs to start with by the HSE?

Dr. Tadhg Crowley

It is very important not to confuse buildings with people. I got involved with primary care centres at the very start and there were many promises about them. We are working in a fabulous centre but it really is about people. We can misplace the idea of primary care centres as a panacea for the problem. The problem really goes back to people. As others have said, between 2010 and 2020 there was a 10% increase in the population and 44% of those were aged over 65. In the next ten years, there will be a 7.5% increase in population and 35% of those will be over 65. There is a health tsunami heading for the country with regard to chronic disease and this affects older people more than younger people. Coupled with this is a shortage of GPs coming to the area. Although the primary care centres are welcome, they are not a panacea in getting new GPs into the system.

Dr. Madeleine Ní Dhálaigh

I agree with Dr. Crowley's remarks. I wanted to give my insight. I have been a trainer on the Ballinasloe training scheme for young and emerging GPs for the past 12 years. Each year, new GPs training would join our practice for training and mentorship. It is crystal clear these GPs are reluctant to take on partnerships or set up a practice.

Unfortunately, I must bring up those savage Financial Emergency Measures in the Public Interest, FEMPI, Act cuts, which saw more than 40% of the gross envelope of funding to provide GP services removed overnight during the crisis. It hollowed out GPs, causing lay-offs and emigration among our colleagues, even some quite established colleagues who had to leave. This did not happen in a vacuum. Our young GPs now were students at that time and non-consultant hospital doctors. They were citizens of the State and witnessed what happened. There is a deep insecurity among them now as a result because, as Dr. Crowley said, they are possibly coming to general practice with loans and at a time they may have young families, be extremely busy or be taking on mortgages.

They are deeply insecure about entering into a financial situation where they may have incomplete support. As Mr. Moran said earlier, we need enhanced supports for these young and not so young GPs who are starting off. We need to look at tax relief and assisted funding for premises and equipment. We also need partnership pathways support and mentoring. Until we can do this, confidence among our emerging GPs will not be addressed properly.

Those are all important points for the committee to take forward.

What percentage of GPs are part of the out-of-hours infrastructure such as Westdoc and its equivalents? In my area west of Galway city, which includes Moycullen, Rosscahill and Oughterard, some GPs are not part of Westdoc. They tell us of the pressures they are under regarding providing cover. The HSE has been given an additional €10 million this year for GP services to deal with the pandemic. I was urging that some of this funding would go to enhanced Westdoc and equivalent services. What percentage of GPs are in these services?

Are there capacity issues in the universities or is it the case that sufficient graduates are coming out of the system but pressures and obstacles in establishing themselves in the country are the main issues in keeping our highly trained graduates here and working in the Irish healthcare system?

Mr. Val Moran

I will deal with the Senator's first question on out-of-hours services. There is a particular situation in Galway but the vast majority of GPs are members of some form of co-operative or out-of-hours arrangement. It is a very high percentage, around 97%, I believe, but I can get the exact figure for the Senator. Even where there are such arrangements in place, there are significant issues, for example, rosters can vary and GPs working in more remote areas are more likely to be on duty more frequently. All GPs in most areas must pay for the red-eye cover, which is where they pay for a locum to cover the 10 p.m. to 8 a.m. shift. There are significant problems with the out-of-hours services. We are seeking a review to make sure the system becomes more equitable for all GPs working in it, individual GPs incur less cost and these services become less of a barrier for GPs to enter into the system. Perhaps the ICGP will address the training aspect of the Senator's question.

Dr. Diarmuid Quinlan

I thank Mr. Moran. I will give a personal perspective on the GP out-of-hours issue. I am in Cork and work with SouthDoc. Last Friday, I worked a full day in my surgery before starting work in SouthDoc at 6 p.m. and working until 11 p.m. doing house calls and seeing patients. It was very busy. Our SouthDoc commitment is on top of an already very busy workload. My rural colleagues have a very onerous out-of-hours rota, which again is a further disincentive to GPs choosing to work in rural areas.

The Senator asked about universities and training places. We are training a substantial number of medical students in Ireland. A new university medical college started in the North of Ireland this year. We have a substantial number of students but we do not have sufficient intern places for all of our graduates. I would like to see more GP intern places. That is the key time at which young doctors decide on their future career. I would like to see more GP intern places, followed by more GP training places or training posts in the various specialties in the hospitals. There is a major shortage, particularly in some specialties, of training posts in hospitals. This would also help my hospital colleagues in training their particular specialties. It would benefit the wider system but particularly general practice. We certainly need more GP intern places and more specialty hospital places which provide a pipeline into GP training.

Dr. John Farrell

I agree with Dr. Quinlan that we need more GP intern places. With the numbers of graduates, however, not all of them will go into general practice. We need greater exposure of general practice in the medical schools. This is something we are going to try to address with the individual universities.

On the Senator's point about starting up in practice, if people do not have access to the GMS list, it is extremely difficult to start up in practice without any patient load. Financially, it is just not viable. As my colleagues from the IMO said, we need to find ways of encouraging people to start up in practice to ensure we have GPs throughout the country to address healthcare needs, particularly among our ageing population which has been the difficulty of late.

I welcome all of our witnesses and genuinely thank them for their comprehensive opening statements and the impressive supporting information presented to us. I am grateful for that. It helps us as a committee when we get that level of detail.

I will first make a number of broad points before I put my questions. I was one of those who asked to have this session to put a focus on GP capacity. In recent times, we have had some anecdotal evidence from constituents and others about waiting longer for GP access and difficulties in accessing out-of-hours services. Some people are unable to find a GP with whom to register. This applies not just in rural areas but also in Dublin. Obviously, there are capacity issues and these are very well set out in the opening statements.

We need to increase GP capacity. I will get to this in my questions. We also need to look at how we better support GPs when they qualify and want to establish practices. There are issues in those areas, as has been highlighted, and also in expanding GP teams.

I will start with the data and facts. The IMO and ICGP are pretty much on the same page with the figures. We have some 3,500 GPs. We have 30% fewer GPs per head of population than in England. The Department recognises that we need an increase in GP numbers of between 37% and 48%, and that we need to train more GPs. To take the calculations, according to the IMO opening statement, some 20% of current GPs will retire in the next five years. This means 700 of the current cohort of 3,500 will retire and must be replaced. We also need to hire between 1,260 and 1,660 additional GPs. Taking the midpoint of 1,500 additional GPs and add the 700 who will retire, it means 2,200 additional GPs will have to come into the system by 2028. By my calculation, that is 366 new GPs every year which is much more than the numbers we are training every year. We can see the problem here and, to be honest, it is because for the past ten years, we have not done what needs to be done in increasing capacity.

Are the current figures on the need for additional capacity and additional GPs based on a no-change policy? In other words, are they based on existing levels of service? As we all know, there is an all-party agreement to transition to universal GP care which will, I imagine, place additional demands on the system. We must look at the demographics and what that additional demand would look like. When we say somewhere between 1,200 and 1,600 additional GPs are required, is this built on a no-change policy or does this build into it the move towards universal GP access?

Dr. Diarmuid Quinlan

I am not sure, on the basis that these are HSE figures. We can certainly clarify those and come back to the Deputy on that.

What is Dr. Quinlan's assumption? Would Dr. Quinlan have a view that it would be based on a no-change policy? I will put the question differently. As we transition to universal GP care, will that increase pressures and demands on general practice generally?

Dr. Diarmuid Quinlan

We are very clear. We have very good research from Ireland showing that when children aged under six got free access to GPs their consultation rates went up 30%. This is to be welcomed because the evidence also shows that these children who had to pay for access to their GP were actually consulting below the international norms for seeing their GP. It was not that these children became excessively consulting; they actually reached the international norms. While we would support increased access to general practice we need to recognise that there is currently very substantial constraint capacity within the system and increasing demand in a constrained system is a very difficult proposition.

Will Dr. Quinlan please answer my questions on what is possible, how many people can be trained and what is needed? Taking the mid-range figure of 1,500 additional GPs by 2028, we know that it has been estimated that 700 GPs will retire, then 2,200 GPs will be needed over the next six years. Given that currently we train 258, and the ICGP wants that number increased to 350, then we are not going to get there by 2028.

Dr. Diarmuid Quinlan

I agree with the Deputy. I think that is also why we are looking at very substantially expanding the number of GP nurses and allied healthcare professionals. If we can bring in GP nurses to support, as they are already doing with vaccinations and chronic disease management, they have a very valuable role. If we can use phlebotomists, healthcare assistants and more practice nurses to support our work in general practice, that will create additional capacity within the existing GP workforce but, fundamentally, we have a major shortage of all primary healthcare staff currently.

I seek clarity on the figures. When Dr. Quinlan said that the ICGP wants to increase the training capacity to 350 can that be done quicker? Realistically, when can that figure be achieved?

Dr. Diarmuid Quinlan

The current plan is that it will be achieved by 2025-26. There are very substantial constraints in the hospital training posts. We need high-quality training posts for GPs so that when they emerge from their training they can actually practice autonomously.

Some of Dr. Quinlan's colleagues in the IMO have raised a hand.

Dr. John Farrell

We have all agreed that there are certainly capacity issues in general practice. We have identified those and we have gone some way to identify the numbers needed over the next few years. General practice training has come under the remit of the ICGP since October. Before that there were 14 different training programmes that were roughly based around the old health board areas. It is, therefore, only in the past number of months that the responsibility for GP training has come under the aegis of the ICGP.

The structure of GP training means that two years are spent in relevant hospital posts, in the subspecialties, and two years then spent in general practice in a mentorship model learning the ins and outs of general practice on the ground. There are not sufficient hospital posts to accommodate the GP training numbers. That is a barrier to expanding the numbers more quickly and, therefore, we have to engage with the NDTP and other organisations to try to ensure that we have sufficient hospital posts for the first two years of the training of our junior colleagues, and then we have to ensure that there are sufficient trainers to increase. The Deputy is quite correct about the numbers. We have to look at making things a little bit more attractive to encourage people to stay on so that 700 people will not retire and that we can get more people into general practice. There is no quick-fix solution.

I wish to ask the IMO a question because we have very limited time and, unfortunately, we cannot get to everybody for responses. On additional capacity, obviously there is a commitment from the political system to deliver universal GP care. We have a system that is under fierce pressure and we need additional capacity just to stand still. I know that there is a plan to increase training capacity. I support the calls for additional supports and flexibility in respect of staffing subsidies and establishing practices.

I have a question for Mr. Moran on the working group that has been proposed on GP practice. For nursing, for example, we have a safe staffing and skill-mix framework. We need something similar for GP practice that would look at the science and tell us how many GPs we need, how we are going to train them and then it is up to the political system to deliver on same. If that work was done and we had a commitment to do that, as well as looking at the flexibilities in how we better support the young GPs coming in and establishing practices, and the other issues that have been raised, and as a quid pro quo then from the political system to GPs, could GPs in a realistic timeframe of, say, over five or seven years, deliver universal GP access?

Mr. Val Moran

The Deputy has raised a number of issues. I will touch on the NDTP report. The 1,260 figure is based on under-18s coming in but that is on a standstill basis without any retirements. Again, the number is much higher and is probably in excess of 2,000 if the number of retirements is taken into account.

Universal GP care needs to be done. Of course it is a laudable ambition but there is absolutely no point in replacing one barrier, which is cost at the moment, with another, which is time, if we are going to create waiting lists within general practice. At each point it needs to be examined to see the effect on capacity. At the moment we are saying we have 0.69 GPs per 1,000 of the population and the NHS, which has its own issues, has 1.1 per 1,000 and, therefore, we would need to significantly boost capacity before we could do that. Would it be possible in that timeframe? "No" is the answer because we simply do not have the capacity in the system at the moment.

The political system and the public need to hear what needs to be done to support GPs in general practice. If there is a commitment from the HSE and the Department that a framework is put in place to increase capacity and the issues that Mr. Moran has raised in his opening statement such as barriers to establishing practices, greater flexibility in staffing, the mix of staffing in general practice and so on were addressed, surely there would be an expectation from the public that the quid pro quo for that is the decision by the political system, supported by the people to deliver universal GP care, could then be implemented. I accept there are capacity problems and that a lot of that needs to be addressed. We also need to hear from representative organisations that if the political system steps up to the plate and provides that capacity, there has to be a quid pro quo.

Mr. Val Moran

There does. We are in favour of universal healthcare but the timeframe that has been mentioned is very tight. The quid pro quo is access to GP services. At the moment, even within the system that we have people cannot access the GP and in many areas they cannot get on a GMS list or must wait for a period. We need to increase that capacity before we can really look at anything. We already have commitments relating to the under-12s and moving on to children aged six and seven and going through that. That is a starting point and we need to look at how that affects capacity as we go through that and roll that out in a measured fashion. If we increase the capacity that will be fantastic but if we are unable to do that properly then we are just going to create waiting lists within general practice and the situation will be a lot worse than it is now. There is no point in having free care if one cannot see a GP or must wait for two weeks to see a GP.

Obviously we are in favour of universal healthcare but it needs to be done in a measured fashion where we are able to say, and assess at each juncture, what is the capacity now, what is the likely effect of the introduction of further free GP care, and whether we have enough capacity to do that in a safe fashion, which is going to increase access in an equitable manner for all citizens. At the moment, we have a hybrid system and it is not perfect but waiting times are nowhere near what they are in the NHS. We are aware that the NHS has 1.1 GP per 1,000 population so we need to significantly increase capacity. It is something that we should all aim for in as quick a manner as possible but also in as safe a manner as possible. If we introduce a situation where a patient cannot see a GP within a certain timeframe then that is a dangerous situation to be in. We need to be very careful on this and we need to do this in a planned fashion. Putting a timeline on that is difficult. We need to see how the measures take place and to see whether capacity is being increased in a measured way, and if it is, then we would proceed on to the next stage.

I apologise to the witnesses who are trying to get in. Many of the questions that are being asked will probably be dealt with in the next couple of rounds, so everyone will have an opportunity to contribute. I apologise to those who are waiting. I call Deputy Lahart.

I apologise for the delay as I was speaking in the Dáil. I thank the witnesses and I thank GPs for keeping the show on the road. It is very much appreciated by those of us in the Parliament. Many GPs will have been in contact with public representatives during this time to raise particular issues. I do not want the meeting to go by without acknowledging the critical role that GPs play, not just in maintaining continued care of patients, but also in continuing to roll out the vaccine which has kept people safe.

Although this might sound a silly question, what is an assistant GP?

Dr. John Farrell

An assistant GP is a fully qualified doctor who is employed after qualification by an established practice. They would usually be salaried by the practice they are employed in. They may not be a partner but they might aspire to partnership or they may just be getting some experience in general practice before they go out and try to work on their own by getting a GMS contract and establishing themselves in practice. It is somebody who is working with an established GP on a salaried basis.

Will the witnesses expand on some of the potential solutions outlined in the IMO submission? What are the particular pinch points? I represent Dublin South-West, which moves towards the mountains and takes in Rathfarnham, Templeogue, Greenhills, Citywest, all of Tallaght, Knocklyon and Ballycullen. What is interesting to me as someone who comes from Rathfarnham is that Scholarstown Road runs from Marlay Park to Oldbawn and there is no GP practice south of that road and no GP practice has been established, although there are thousands of houses. We have a new primary care centre coming in Ballyboden and Tallaght is reasonably well provided for in terms of primary care, so, moving north of that road, there is a reasonably plentiful supply of GPs. Through bereavement and retirement, there has been a loss of GPs. The impact the loss of just one GP has is incredible, and I know some local GPs would have up to 8,000 patients on their books. That is just the geography of it. It has always struck me that in all of that newly developed area which has developed over the last ten to 15 years, there is no GP practice. What can we do to help deal with that?

One of the things I have been conscious of is that if GPs have a family practice, it tends to be the end house converted into a practice. Even in the planning system, we do not make provision for GP practices in new developments, although we make provision for preschools, village centres and so on, and a GP may get the top floor position in that. Is it something the witnesses have a view on? Would it help if we included it in the planning requirement for an area?

Dr. Diarmuid Quinlan

I am from Glanmire. When I drive around, I see massive building going on at the moment in Glanmire and we have not expanded our GP capacity anywhere near sufficiently to look after these people. I share the Deputy’s pain in regard to his constituency and I know Deputy Colm Burke in my constituency will feel the same. This is a widespread problem. In terms of looking at solutions, the ICGP proposes a working group on the future of general practice so we have a strategic, high-level working group to accurately identify and work through the solutions. Looking at the GP workforce is fundamental but that will take time, as Mr. Moran said. It is also a matter of looking at the wider primary care team of GP nurses and allied healthcare professionals to support general practice and to support GPs, so we create capacity within the existing system. That may represent a shorter term solution but there are no quick fixes.

One of the points mentioned by Dr. Quinlan is support for a healthcare system within general practice. Will he explain again to us, as laypeople, what role the healthcare assistant plays, why they are so important and what kind of support is being sought?

Dr. Diarmuid Quinlan

A healthcare assistant is a highly trained person who would not have the same skill set or qualifications as a nurse but would do some of the tasks that a nurse currently does, for example, 24-hour blood pressure, ECG, phlebotomy and taking blood and, potentially, adult flu vaccinations, among other things. A healthcare assistant will take some of the work from a nurse and allow our highly skilled practice nurses to increasingly do the more skilled work which is well within their capability and capacity, such as chronic disease management, advanced nurse training and nurse prescribing. By bringing in people with a lower skill set, it increases the capacity and we get the correct skill mix within the primary care team.

A number of witnesses are waiting to contribute. Does Deputy Lahart wish to bring them in to the discussion?

I will bring them in. The specific question is how, as Government Deputies, we can advocate for GPs and the supports they specifically require around that healthcare assistant piece.

I call Dr. Crowley.

Dr. Tadhg Crowley

I thank the Deputy for the question. In terms of how we help GPs, it is the GPs on the way in, the GPs who are already there and the GPs who are on the way out. If I take the GPs who are already there, because that is the focus of the Deputy’s question, at the moment we get allowances for certain staff members, such as a nurse or a secretary, but it is very defined as to what we can do. For a practice such as a group practice or a single-handed practice, it would be better if the practice was allowed to take the pot of the allowance and decide what is required for its particular area. This would mean not only healthcare assistants but also an allied health professional, such as a psychologist or a counsellor, could come in to add to the pot of treatment that a GP or a group of GPs can provide in the area. That would be very important.

In areas where GPs are single-handed, we must remember that GPs do not go into general practice because of business; they go into general practice to treat patients. In my case, I arrived to find that I was running a business and no one had ever explained what this was about as I thought I would just be treating patients. Some people are very good at business; they were not trained that way but they were born that way. If there was an allowance between four or five practices, GPs could have a practice manager who would allow them to look after the general practice side and allow the manager to look after the management side. That might make it easier for the GPs who are already there.

In terms of GPs who are coming into the system, as we mentioned earlier, it is financially crippling for a GP to come in who does not have an established practice to join. It is about trying to help them establish, first, with the various grants we alluded to earlier, but also with a hub and spoke model that allows for single-handed practitioners. To be single-handed is very difficult in this day and age. The GP is an employer and a doctor and has legal responsibilities, and there is a lot of stress. In an environment where we are looking at work-life balance, the GP is going in the opposite direction when we are trying to encourage people, first, to go into general practice and, second, to establish themselves.

GP practices used to just spring up in days gone by and the public certainly would not have been aware of a difficulty in establishing a practice. What are the particular difficulties in establishing a practice now? Is raising finance one of those, as a matter of interest?

Dr. Tadhg Crowley

It is huge. First, the days of people coming out of college debt-free are gone. Most students, particularly postgraduate students who have gone into postgraduate medicine and do a degree somewhere else, go back in at 24 or 25 years of age and by the time they leave medical school, they will have a debt of approximately €100,000 to pay off.

They could go to a financial institution to borrow money to buy a house to set up, because that is what is required but a house, with the various health regulations that are there, must be equipped and invested in. It is not just a matter of buying a house; they have to equip it to meet certain standards. Then they have to employ people on top of that, including practice secretaries and practice managers. Before they start practising at all, they could find themselves in debt to the tune of close to €1 million. No bank, in this day and age, is going to give the imprimatur to them to set up and all will be fine. It just will not happen.

Does Dr. Ní Dhálaigh wish to respond?

Dr. Madeleine Ní Dhálaigh

I thank the Deputy for his question. A good way to look at this is to compare the urban and rural situation. The Deputy referred to a large area in his constituency where there is no GP. In the same way that IDA Ireland supports business, we need to consider something similar for our young or emerging GP colleagues. If two GPs want to set up, as Dr. Crowley has just said, the financial barriers are enormous. They are at a very difficult stage in their lives, with young families, their own personal mortgages and their own personal debt from college fees. In that context, we need to look at supporting GPs in much the same way that IDA Ireland supports our business colleagues. That could include providing tax relief and help with the cost of premises and equipment and with set up fees. Our GPs are highly trained and highly qualified and what the State will receive in return will be a multiple of what it invests.

Regarding our rural colleagues, what we are seeing now, and this is no longer confined to just the western seaboard, is significant difficulties in getting emerging GPs to take up lists because of remoteness and poor out-of-hours cover. Furthermore, small lists with very little other income apart from the GMS list, means that many practices are not financially viable. That has to be looked at as well because it is not just an issue along the western seaboard but right throughout the midlands as well. I know of a practice close to Kilkenny city that has been finding it extremely difficult to find a GP, as Dr. Crowley can attest. We have to tackle this.

Universal healthcare through Sláintecare is a great aspiration that I very much support but emerging GPs do not want to be left on their own, where they have to create waiting lists, they are isolated, they have financial burdens and are referring into a void because there is no secondary care for their very unwell patients. Let us say a young woman or young man attends a GP with a cruciate injury sustained in a weekend sport. The GP will try to arrange secondary care but that patient will not even be seen for two years, not to mind getting treatment. All of these factors are making GPs very reluctant to set out on their own without supports. We have to support them.

I am going to conclude on this. As a member of a Government party, this is the first time this pitch has ever been made to me. I ask, if not implore, the IMO, if it wants to take this further, to put flesh on the bones of what is required. The idea of an IDA Ireland-style start-up grant scheme sounds very practical, given the crisis that exists in GP provision nationally. If the IMO has not done so, I urge it to put together a detailed list of what is required in terms of start-up grants, subsidies and so on that would enable GPs to establish themselves. It would then be up to politicians to advocate for that. A detailed pre-budget submission could be prepared over the coming months. I am not throwing this back on the IMO but I am interested in advocating for this and I am sure my colleagues on this committee are too. I did not appreciate that the debt a qualified doctor emerges from medical school with was so large. On the planning side, it is not right that a doctor has to buy a house and then furnish it. GP practices should be constructed within all new developments and offered to GPs, with some kind of deal around paying back or leasing back over time. That would be one way around that difficulty. I do not know if that sounds terribly patronising or if the IMO has been over this ground previously but I ask the witnesses to give a brief response.

Mr. Val Moran

We will certainly pull together some documentation on that. These are issues that we have raised previously but we would be happy to do that.

I will move on. I apologise to the witnesses who did not get a chance to respond. If members see that a witness has raised his or her hand, I ask them to allow them in. I do not want to break the flow of the conversation but ask members to bring witnesses into the discussion whenever possible.

I welcome our guests. It is important to acknowledge the essential role that general practice has played in the health service down through the years. General practice is very much the front line and the first point of contact for people. Traditionally people have been vary satisfied, in the main, with the level of care being provided and the accessibility of their local GPs. The relationship between patients and GPs is a very trusting one. I say that notwithstanding the difficulty that many people have in accessing care as a result of cost barriers. That is very much central to the approach taken in Sláintecare. It is about removing the cost barriers but it is also about refocusing the health service away from the very expensive acute hospital system and putting a major focus on general practice. That includes doctors and all other essential healthcare workers at primary care level.

There are major opportunities for GPs to be part of something that is really transformative for our health service and that is what the public wants. It makes sense for people to be able to access care at the earliest stage when an issue develops for them. It also makes sense for them to have an ongoing relationship with general practice. In the main, people want to access care locally from people that they know and trust. That kind of approach is very much enshrined in Government policy and in Sláintecare and that is why it is really disappointing that we find ourselves in a situation where there is a commitment to vastly expand general practice and primary care but we do not actually have the staff to do that and there are real obstacles in the way. One of those obstacles is the current model of care. While acknowledging the fantastic work that has been done down through the years, it is also important to acknowledge that private contractor, single-handed practice is a model that is no longer attractive to younger graduates. There must be a way of acknowledging what existing GPs are doing, supporting them better in that while also developing a new model that recognises the desire and the needs of new graduates.

We know from the HSE's updated workforce plan of November 2020 and from the very extensive research that has been done by the ICGP that younger doctors do not want the kind of model that has been in existence from the beginning of this State. We have to recognise the fact that people are working to a 50-year-old contract, albeit one that has been updated somewhat. It just does not meet the needs of patients or medical graduates. Research shows that medical graduates want a better work-life balance and they want to be working in multidisciplinary teams with a much better skill mix. They want to be medical practitioners as opposed to businesspeople.

Many of the people graduating from medical school are broke as it is because of the cost of that. They do not want to be in the position of having to take out a mortgage to buy a premises. They want to concentrate on providing healthcare, in the main. The proposals from the ICGP need very serious consideration. In the absence of updating the contract and the model of care, what has happened, as mentioned by all of the witnesses, is that we now have a severe shortage of GPs. The impact of that is that in areas all around the country people cannot access basic primary care. This applies in rural areas as well as in urban areas. As Deputies, we are increasingly getting queries from constituents who cannot get on to a GMS panel to access a general practitioner. We know that the inverse care law applies. The inverse care law is that the more people need healthcare, the greater the need, the less likely they are to be able to access that care. We know from the witnesses' colleagues in Deep End Ireland that there are serious, major problems in areas of high urban disadvantage. The existing model does not address that.

Because we are not addressing those key problems, we are seeing the corporatisation of primary care. That is not desirable. The big companies are coming in from abroad and running general practice. That is not in anybody's interest. Unless we address the fundamental underlying problems, that trend will continue and we will lose all of those good elements of primary care and general practice. We have to listen to what the ICGP is saying. Its proposal around a high-level working group to address these underlying problems is key. I would hope that as a committee we would take up those issues. The problems go much deeper than tax reliefs for the existing model.

I have a question for Dr. Quinlan. To what extent has the ICGP engaged with our many medical graduates in recent years who voted with their feet and have gone abroad to work in other healthcare systems that provide work-life balance, premises and opportunities for part-time work that younger GPs are looking for now? How much has the ICGP engaged with those people and what are the primary reasons for them emigrating?

Dr. Diarmuid Quinlan

I thank the Deputy for the question. General practice is a fantastic, rewarding, intellectually stimulating career. There are financial challenges, as expertly outlined by Mr. Moran, but it is a phenomenal career. This week, I had in my practice a young doctor who had just returned from Scotland. She was engaged in my practice as a medical student in 2014. She has an interview for the ICGP training scheme in February. We are engaging continuously and we are reaching out internationally to support and bring people back. I have also had a report from a colleague who moved to Scotland recently. She tells me that the big different between her working as a GP in Donegal and working in Scotland is that she has enormous supports, such as have been described here today, in terms of healthcare systems, GP nurses, advanced nurse practitioners, nurse prescribers and a great deal of administrative support, including practice management support. These are all of the requirements we have highlighted in our document, including the working group. My colleague has all of those supports in Scotland, which enables GPs to work at the top of their licence throughout their working day. We are working very closely to recruit young GPs to this fantastic career. The financial piece is important. As mentioned by Dr. Crowley, he is a doctor primarily not a businessperson. I would look forward to working on the ICGP collaborative working group with all of the stakeholders to look at the future of general practice. It would be a high-level working group with real muscle to deliver.

I note Dr. Ní Dhálaigh is indicating that she would like to come in.

I would like to ask Mr. Moran a question. Clearly, premises has been a problem. I have previously made the point that we would never expect school principals to provide their own schools. We have highly trained GPs. Surely, it makes sense that the State would provide premises for them, along with all the other health professionals required to work in a multidisciplinary team. What is Mr. Moran's view on the State providing premises for GPs, working either as salaried GPs, which has been mooted in the past and which I know a lot of young graduates would be interested in, or on a contract basis?

The other side of that is that there would be a recognition of the costs incurred by existing or established GPs in providing those premises. Surely, it is possible to address that issue. We end up with these ridiculous rows about the rent that the HSE is charging GPs to use the State primary care centres. What proposals has the IMO brought forward to address that issue and to ensure that people are freed up from having to get a mortgage and provide their own premises?

Mr. Val Moran

There are a range of issues in regard to premises. As the Deputy will be aware, in the current system, there are HSE-owned premises, developer-owned premises and GP-owned premises. These are primary care centres that are well set up with a variety of different systems in place. With regard to the contractual position, the contractor basis is the preferred model. There are employed GPs within general practice. They are working with other GPs. Most of the studies show that while initially some GPs want to work as an employee, they later want to set up in practice. It is very difficult to see how two different models could exist side by side.

On the premises point and the system operating on a contractor basis, the support that would be there would be welcome. Previously, GMS premises were often provided free of charge, but that was a part of the work to get a GP into an area. That took away that cost. There are a significant number of GPs who have invested in their practices heavily over the years. That would need to be taken into account when looking at something like this. If that were the case, it is something that should be looked at. There is a difficulty sometimes with primary care centres getting GPs in because there is a rent to be charged by the HSE to the GP and then the GP is working in another premises down the road. Obviously, that does not make sense.

There are two elements to my final question. Why is the IMO opposed to a new model of care? Why does it not recognise that there can be two different models of care, that is, one for existing GPs and those who are established and that being an option for new GPs and a different model for those GPs who do not want to invest in premises and want to work solely as GPs in a multidisciplinary team? Would Mr. Moran accept that it is possible to have a dual model?

Second, I ask Mr. Moran to comment on the creeping corporatisation of general practice and if he sees that as a major problem.

Mr. Val Moran

On the first issue, that model already exists for a GP who wishes to work solely as a GP focused on clinical issues. The GP works within a practice but is not a partner within that practice.

I am talking about working for and being paid a very good salary by the HSE.

Mr. Val Moran

That potentially would mean two different contracts under one system and, possibly, different set-ups in terms of the level of care that is there. It would lead to a fragmented system. We believe that whatever system is there should be a unified applied system. For the individual GP, there is progression through the existing system if he or she wants to work as a salaried GP for a time, which some do, and then set up in a practice. They can do that. If we take away the entrepreneurial aspect of general practice, what then happens with the out-of-hours services? For example, would the employed GP also do out-of-hours duties?

We need a model that addresses that.

Mr. Val Moran

That is a whole different conversation. In terms of what has happened within healthcare in this country over a number of years, we have constantly stated that we need to go back to the drawing board, we need a new model and that we need to replace this and replace that.

Sometimes we need to accept that we have a model and we need to improve it to the greatest extent possible.

Or we could manage two different models.

Can we move on?

Mr. Val Moran

That is a political decision but, in our view, the existing independent contractor model is the model to continue. It would lead to significant problems if we changed it from that.

I just think there is a difference-----

Deputy Shortall said it was the last question. Could she finish up?

What is Mr. Moran's view about corporatisation?

Deputy Shortall said a few minutes ago that it was her last question. She is moving on to another question now.

I already asked this.

Mr. Val Moran

Corporatisation is increasing and it is an issue. There are a lot of good GPs working within corporate set-ups. It is changing. The GMS contract is with an individual named GP. A corporate entity cannot enter into a GMS contract. It has to be a doctor registered with the Medical Council who has a GMS number. The contract the HSE has is with the individual GP. While there might be entities beyond that set up in certain circumstances, the package of care is provided by that individual GP. Notwithstanding that and the fact that the contract with the State must be entered into by the individual GP, we are seeing more of these practices set up where a limited entity is behind that. It is a reality.

It is also a problem.

Mr. Val Moran

It is potentially an issue.

I apologise to the witnesses who were trying to get in but were not brought in during the discussion. I again appeal to members with issues to raise to bring them in as part of their ten-minute slot. It is impossible to chair the meeting and break the flow of the questions and contributions by members. Members should bear in mind that people are giving up their time for this meeting.

I thank all our witnesses. It has been an extremely difficult two years for everybody. Hopefully, an end to the pandemic is in sight. It has probably been the most challenging two years for every medical professional. Anybody working in this field came across people in quite stressful situations. It was, and continues to be, the medical profession's greatest hour. We owe the profession our ongoing gratitude.

Deputy Shortall touched on a number of my questions. It is obvious that we need more GPs. What effect has the emigration of qualified graduates, particularly in the past ten years, had in terms of GPs who could have worked in the health system but went abroad for a variety of reasons?

Who wants to take that question?

Dr. Diarmuid Quinlan

I was a graduate who emigrated. I came back in the late 1990s, which was before the time of austerity. We have a long tradition of doctors emigrating, gaining experience overseas and coming back. Unfortunately, many doctors emigrated during the decade of austerity and stayed abroad. That is part of the workforce deficit we are experiencing.

Dr. John Farrell

I agree with a lot of the points that have been made, particularly about corporatisation, the longer waiting times for GPs and people who cannot find GPs. They are all serious issues that are reflected in the capacity issues we addressed. As Dr. Quinlan said, there is a long-standing tradition of Irish graduates going away, getting experience in other healthcare systems and bringing back new ideas. That has happened. What we need to do now is attract them back and make sure they stay so it is as much about retention as it is about recruitment. Bringing people back is the challenge facing us now. I echo what others have said. General practice is a wonderfully rewarding career. A number of organisations within the college are very active. A continuing medical education network provides support to GPs who are working and trying to ease their workload. We also have a network providing practical supports to people trying to establish a practice so we are doing our best with the resources we have but it comes back to the issue of capacity, which we all identified. We have called for a high-level working group to address the needs we all identified and were clarified by everybody in this meeting.

Dr. Madeleine Ní Dhálaigh

The Deputy's question is a good one. As we all know, the effect of emigration down the years across the board has been multifactorial but what all younger GPs saw when they went abroad were highly functional systems of care in both primary and secondary care. Primarily we are doctors and we want to work in really high-quality systems. It is very difficult for them to come back to Ireland and see this quite broken system of care. One issue is very close to my practice because I specialise in women's health. The way other countries such as Australia deliver women's healthcare is fantastic. The underinvestment that has been the case for decades in this country has been informed culturally, which is something we all know a lot about. We should be leaving this culture behind. The recent highlighting of menopause care and the ad hoc approach in this country was very welcome because it was something GPs had been talking about for a long time but menopause care is just one aspect of women's healthcare. We need to look after our women and girls from adolescence through to their child-bearing age and menopause. Regarding the very specific example of menopause, those are highly complex, individualised consultations that GPs are not funded to do under the GMS system so we are doing them on a pro bono basis. They are not once-off consultations. We need to see these women on a regular basis and we need to be dynamic in and individualise their care.

I am an early abortion provider in a rural community in Castlerea, County Roscommon. This has shed light on a very difficult hidden fact in Irish women's healthcare, namely, that working poor women will never prioritise their healthcare needs above those of their children and families. We see a high proportion of women who are unable to afford good-quality contraception so they now find themselves with unplanned pregnancies. Thankfully, they can now access care in Ireland. We really need to look after women and girls from the time of adolescence right through to contraception for all women who need it and really high-quality menopause care. To bring it back to the question about emigration, for me looking at other countries and coming back to this healthcare system, that is a really good example of how emigration has affected us.

Regarding corporatisation, in other countries, GPs can access retirement planning and feel very comfortable with it. The corporates are probably the only area that offers retirement planning. The State needs to sit up and take note because there is a place for them in certain circumstances but our current model should not be dismissed. Again, our rural colleagues have given significant service to this State and worked onerous rotas in very isolated practices single-handedly.

While it is important that we move towards group practices, we have to acknowledge what they give. We cannot throw the baby out with the bathwater by taking away rural services and moving them into group practices. We need a hub and spoke model and we need to continue to provide dynamic, responsive rural care. During the pandemic, we could see how our rural colleagues stepped up in very isolated situations. We need to acknowledge that.

My final question is on free GP care for children. Six or seven years ago, free GP care was introduced for children under the age of six. That had an effect on capacity. The Government has introduced free GP care for children aged six and seven, which is great. Most of us will agree that universal healthcare or Sláintecare, whatever we like to call it, is very positive. I am making a political charge rather than a medical charge in saying some of what we hear on the issue of universal care is lip service. What effect is free GP care for six- and seven-year-olds having in the witnesses' practices?

Dr. Diarmuid Quinlan

First, I agree with Dr. Ní Dhálaigh that women’s healthcare has been historically underprioritised. The ICGP has recently commenced a community gynaecology course, with more than 200 GPs logging on for each module of that. With the HSE, we interviewed and are due to appoint a women’s health lead. These are very positive steps. However, I agree with Dr. Ní Dhálaigh that there is substantially more that we can do.

Coming back to the expansion of GP care to children, in principle, it is a fantastic aspiration. However, in practice, giving free GP care when we know many patients across Ireland already have substantial difficulty accessing their GP in a timely fashion increases the burden and demand on an already constrained service. Therefore, while it is a very noble aspiration, we need to recognise that we are in a difficult place in terms of our workforce in general practice and our ability to deliver that care.

Mr. Val Moran

To be clear on that, the IMO, as part of the 2019 GP agreement, has agreed to enter into negotiations on the further roll-out of free GP care to under-12s, to be done in a phased manner. We have had the pandemic for the past number of years and discussions have not been taking place on that, nor was the capacity available within general practice. As the pandemic recedes, we might expect to see those discussions resume. That should be done in a graduated fashion, with free GP care extended by a couple of years each time and capacity issues assessed.

Dr. Crowley wanted to respond.

There is a problem with the sound. If Dr. Crowley leaves the meeting and logs in again, we will try to bring him back in. We still cannot hear him so we will have to move on. We cannot hear Senator Conway either. I apologise to anyone following proceedings at home. We are having some IT difficulties. Perhaps Deputy Durkan will contribute at this point.

I am ready and willing. I welcome the witnesses and congratulate them on the role they have played throughout the pandemic. It was called upon. They rallied to the cause and that is much appreciated and admired.

Has the new GP contract in any way addressed the issues that have caused problems in the provision of GP services?

Mr. Val Moran

The 2019 agreement has had a very positive effect insofar as it has begun to unwind the FEMPI provisions. It is only this month that they have been fully unwound. We hope that will have further effect as it beds down. However, it is only a reversal of cuts and the restoration of funding to 2008 levels. If we are to improve capacity, we need to directly target that with targeted incentives, for example, in the area of assistant GPs. If a single-handed GP is close to retirement, he or she may wish to bring in an assistant GP who would take over the practice over a period of years. Obviously, that is a sensible transition provision. If the outgoing GP were supported to take on an assistant, it would help address the situation where we see lists coming up in certain areas and no suitable candidates applying for them. That is one aspect.

Is that evolving at the present time to the satisfaction of all concerned?

Mr. Val Moran

No, that is something on which we are making a proposal and there needs to be discussion on that.

Is the IMO getting a response?

Mr. Val Moran

We are in constant engagement with the HSE on it. We are working through the GP agreement as well. The chronic disease management, CDM, part of the GP agreement is being widened from January of this year to include all medical card patients over 18 years of age who have a chronic condition. That is a huge achievement. In fairness to the HSE, it has put a great deal into that as well, particularly in terms of IT support and rolling out that change. That will make a significant difference to patients’ lives and how they are managed within general practice. Hopefully, it will lessen the burden on the acute setting and reduce the number of acute presentations by people with these conditions. That is being worked through. There is also work taking place on community healthcare networks - these are groups of populations of 50,000 - to deliver care at that level and have a GP lead along with a network manager.

All of that work is taking place but there is a wider issue of capacity that we need to start looking at. We want to engage with the HSE, the Department and the political system on that. These are some of the solutions we would see on that.

I am glad to hear that because it is important that progress continues to be made on whatever agreements are reached and whatever arrangements are entered into. Otherwise, they get stuck, left on the shelf and added to the list.

In the event of an all-out effort being made, how can we dramatically increase the number of trainee GPs being accommodated in training? That question has been asked before. There is a necessity to increase that number dramatically in the shortest possible time.

I see three hands raised. Who wants to go into the breach? Do not be shy.

Dr. John Farrell

We have agreed, as I said, that there are capacity issues. One of the barriers to increasing training numbers and making the training as relevant as possible is access to suitable hospital posts. That is where primary care and the ICGP need to co-ordinate matters with the national doctors training programme to ensure we have access to suitable hospital posts.

Is there access at the moment or is access limited or impeded?

Dr. John Farrell

There are ongoing discussions around that. Mr. Foy would be best able to answer that question as he has been dealing with the matter. It is not as clear-cut as we would like at the moment. We have problems accessing some posts.

Can access be improved? Given the situation presenting, what steps are necessary to improve that, steamline it and ensure there is ready access?

Mr. Fintan Foy

I will answer that briefly. The rate-limiting factor to growing the trainee numbers is, as Dr. Farrell said, the access to training posts in hospitals. We are competing for those training posts with all other specialties.

The problem in hospitals is the emphasis on service rather than training. There is an urgent requirement to move service posts to trainee posts. That is a political decision, and then it is a decision that needs to be made locally by the HSE and the hospitals.

We need to know the degree to which positions can be made available in the hospitals. For example, I do not believe that hospitals are overburdened with excess staff, because the pressure is on and the demand is there.

Mr. Fintan Foy

I believe it is also a philosophical change. Within a hospital the emphasis is on service. Training bodies such as ours are saying that we need to move this philosophy of emphasis on service to training. With training, however, one also gets service. That is one factor.

The Deputy referred to increasing the training numbers rapidly. We must also be conscious of the fact that there are only approximately 1,000 medical graduates coming out of the system annually. It would be very difficult for us to go beyond the 350 GP trainees, which we are targeted to get to by 2026, because we are also competing with all of the other specialties. That is also a rate-limiting factor. Training is not a short-term solution but we are committed to getting our training numbers up to 350 within the next three to four years.

Unfortunately, unless we tackle these issues head on and deal with them, we will be talking about the same issues in five and ten years. It is all very well to talk about austerity, which was mentioned a couple of times, but we never had austerity in this country. We had the IMF running the country when the money supply was cut off. It was unfairly cut off to a lot of people who were very deserving, including in education and in health. It was cut off and we had no control over it. We are now in a position where we are trying to rebuild the system again. We do not have the IMF and we must follow certain standards. We have to rebuild the system from the point of view of our constituents and the growing demands of an increased population.

How quickly can we gain access to a greater supply of GPs if we have to take them from abroad? What can we do about that? There is a very lethargic method of dealing with applications from nurses, for example, who want jobs and who want to join here. Nurses may have qualified in the UK but when they make an application to join the hospital services here, they could be waiting six months before the response, or more. They keep complaining to us that they make the application and then the response is slow. We must get out of that situation in a hurry.

A number of witnesses are willing to come in there. Will the Deputy indicate to whom he is asking the question?

Dr. Quinlan and Dr. Crowley.

Dr. Diarmuid Quinlan

Perhaps Dr. Crowley will come in first because I am conscious his line dropped out earlier.

We can hear Dr. Crowley now, and we welcome him back.

Dr. Tadhg Crowley

Apologies, finally my sound is restored from Kilkenny. I thank Deputy Durkan for his comments. Unfortunately, there is no quick fix. There is no state whereby we can magically look abroad and bring doctors in quickly from abroad; it is not going to happen. A problem at the moment is that our GPs have been trained, and the training they get here through the college is fantastic, and then they are well sought after across the world. It has been happening for years that they go abroad, get experience, and come back. Now our problem is that they are not coming back. We are also not getting doctors from abroad coming in, so there is no quick fix. Training more people sounds great but we must be realistic that we are also competing against other medical professionals here for their training schemes. We must train our GPs to a certain level so when they go out they are able to actually provide the service for which we are training them. General practice is a specialty. One does not just train quickly up to it.

I recognise what Dr. Crowley is saying and that there is no quick fix, but there cannot be no quick fix forever. It must be possible to solve the problem at some stage. If we do not put in place the mechanism to deal with it, the public will lose confidence, politicians will lose confidence and GPs will lose confidence, and we will then be in the situation where we are not capable of dealing with the magnitude of the problem that is unfolding.

Dr. Diarmuid Quinlan

I echo the Deputy's sentiments that we are in the midst of a GP workforce crisis. If we look at it in perspective, we went from 159 training places in 2015 to 258 this year, which is a very substantial increase, and it will be at 350 by 2026. It is a very substantial increase. It is a competitive market internationally for healthcare professionals. If we were to look at the allied healthcare professionals in general practice, which is our GP nurses, healthcare assistants, phlebotomists, and administration supports, that would liberate GP time in the short, medium and long term. That does represent a further weapon in our armoury to support general practice in delivering care for patients. A high level ICGP group, with all key stakeholder groups, engaged in looking at the future of general practice in delivering community care, would work through these problems relatively rapidly and come up with workable solutions.

Dr. Madeleine Ní Dhálaigh wishes to come in, and I put the same question to her. We need to respond but if we cannot make a quick fix then let us have some fix in the shortest time possible. If we have to import personnel then let us do it. Let us recognise the problem and address it.

Dr. Madeleine Ní Dhálaigh

I agree that we do, but at the risk of repeating some of the points we made earlier, it should not take a lot of time to increase staff subsidies within practice, and to give us more flexibility around how we use those subsidies. We want to attract our emigrated personnel back and encourage our highly trained personnel not to leave in the first place, in conjunction with attracting people who have not trained in Ireland who are high-quality professionals from internationally. This is absolutely something I would be very interested in looking at.

Points were made earlier about increasing subsidies for staff and making that more flexible, supporting our young GPs in making the decision to join partnerships, and a mentorship model. None of these need a long run-in time. This could all happen very quickly if the will was there. During the pandemic we saw that when there was a will for the HSE to make changes, things happened overnight. Locally, our primary care centre was converted into a clinical hub, built and ready for action within ten to 14 days. When there is a will within the HSE we saw how it worked, they went ahead and did it. Give us the subsidies, give us the succession planning, give us the mentorship, and give us the retirement planning. Then people will be attracted back and people will be attracted to stay. I believe that this should be our starting point.

I will not go back around as we have spoken a lot about training. The figure of 350 GPs out of a potential 1,000 GPs is a fair whopper of a number, and it could be substantial.

Reference is often made to bringing in doctors from abroad. At a previous meeting we had a brief conversation about the ethics of recruiting doctors from overseas and the impact of depleting other countries, and particularly developing countries, of their medical expertise, especially given some of the limited growth opportunities Ireland has for doctors who have come from abroad. This is slightly outside the focus of GPs but it reminded me that we had that conversation. We cannot be outside of the training opportunities for people moving globally. This is very important. We cannot rely on bringing people in. There is an ethical concern and we have discussed this topic at a previous meeting. I just want to flag it here.

Reference was made to women's healthcare, and health care for pregnant people. We are talking about service provision and people being able to access care. Do the witnesses believe that the conscientious objection around abortion care is resulting in a depletion of care for pregnant people?

Would the witnesses say it is a good thing, particularly for those in rural areas? For example, I note that Sligo has no GP that we know of who will provide abortion care. There may be care provided under the radar. People are forced to either travel across their county or outside of their county in order to access timely care. I assure the witnesses that I am not asking for their personal opinion on the merits of conscientious objection, but rather asking them as representative organisations whether they are concerned about this severe lack of options for women or pregnant people in this area. It becomes a bit of a postcode lottery as to whether or not people are able to access timely care.

I have spoken to a few GPs and one of their big concerns is about how they can interact with and support people with mental health issues. They told me that there is essentially no primary care mental health service in Ireland. They noted that people who are not in the GMS have to pay the market rate if they are in crisis and there is no embedded model of care. They stated that mental health accounts for the bulk of GP workload but they are left on their own. They referred to the lack of availability of psychological therapies for non-GMS patients and the months-long waiting list. The cost of psychotherapy for a year can be over €1,000.

These GPs also raised the lack of social management options and told me that nothing is embedded in GP primary care for key workers, or anything like that. In their statements and briefing notes, the representatives of the IMO and ICGP spoke about the more embedded, broader model of care that people will be able to access in GP clinics. I ask them to speak on the issue of mental health. The GPs I spoke to said that one of most devastating things is not being able to offer the mental health care that is crucial at the moment. I put that question to Dr. Ní Dhálaigh and Dr. Quinlan.

Dr. Madeleine Ní Dhálaigh

Does the Senator's question on conscientious objection relate to abortion care, contraceptive care or both?

Both, I suppose.

Dr. Madeleine Ní Dhálaigh

Conscientious objection in the peripheral hospitals has had an impact on abortion care and has an impact on abortion care being provided by GPs in the community. There is an impact if GPs are unsupported by their local hospital and are expected to provide care in a vacuum. For instance, there is no peripheral hospital providing that care in all of counties Donegal and Sligo. I have colleagues who have very bravely stepped up to the mark and are providing high-quality care, but in terms of accessing follow-up care or in cases where the woman or girl has gone over the ten weeks' gestation period, after which point care cannot be provided in the community, their nearest hospital is Mayo University Hospital. The model of care is that it is provided in the hospital. Conscientious objection is something the HSE needs to address in those peripheral hospitals. One will find that GPs will become providers if that is removed.

With regard to contraception, the main barrier to care for women receiving care and all people who need contraception is the financial barrier. There are very few conscientious objectors now with regard to contraception. Women, girls and people who need contraception have a good choice of who provides it, but they need to be supported. There needs to be a structured programme for women and all people who need contraception. I spoke about the issue earlier.

The Senator mentioned mental health in primary care. Mental health care in primary care is non-existent. GPs are really under pressure to provide the care. Again, this speaks to the subsidies. We should be able to use our subsidies as we see fit, perhaps to employ a psychologist for a session or two a week. What we keep talking about is the need for structured and evidence-based care. We will deliver it, but it needs to be evidence-based and properly resourced or it will not work.

Dr. Diarmuid Quinlan

I will answer two of the Senator's questions. One is about the brain drain from low and middle income countries to resource-rich countries. The HSE has signed up to the WHO agreement on that issue. We support and endorse that.

Looking at the mental health issue, this is really important to the Irish College of General Practitioners. Many of our patients have severe and enduring mental health issues. Working with the HSE, we are looking at several issues on that front. The first is the physical health of these people. People with severe and enduring mental illness die, on average, between 13 and 30 years younger than everyone else. There is an appalling loss of life for this cohort. A substantial part of that relates directly to their physical health issues and needs. The second issue is that there is a substantial void in the ability to access counselling for people, when they need it, in a timely fashion. Working with the HSE, we are looking at appointing a GP clinical lead in mental health. Ultimately, we would like to see a chronic disease management programme for people with enduring mental illness, among others, similar to the existing and really good chronic disease management programmes for asthma, COPD, diabetes and heart disease. Mental health is something we are passionate about and on which we are working closely and on an ongoing basis with senior HSE staff to deliver.

Does Dr. Crowley want to contribute?

Dr. Tadhg Crowley

I thank the Senator for her question because it strikes at the heart of general practice and the issues we have. To reiterate what our colleagues would say, I cannot count the number of times that all GPs, particularly those in this room, have been in consultations with severely distressed people with mental health issues who had nowhere to go. Our only option is to keep bringing them back to the practice while we are trying to facilitate public services. GPs are the first line of contact for mental health issues and there are no resources. To reiterate what we are saying in terms of going back to free GP care, sometimes structured care and programmes offer far better value for money for the State and patients. Mental health would certainly fall into that category. It would be high up on the list of any GP working on the ground in Ireland. Mental health issues are huge. The number of cases we have seen in the past couple of years, particularly during Covid, has been very upsetting and distressing. We could spend the day sharing various stories.

Thinking about embedded care, and obviously it cannot be the same as in a college setting, I recall that when I was at UCC, there was a GP surgery downstairs, a mental health service upstairs, a physiotherapist around the corner and a nurse for other things. Obviously, that is one particular setting but all of the care options were provided. It would relieve some of the pressure, as Dr. Ní Dhálaigh has said, if GPs were able to decide how to use that funding themselves and direct it as best they see fit within their own practices. I will leave it at that.

I call Deputy Cathal Crowe.

I confirm that I am in Leinster House. I have been following the discussion. I address my first question to Mr. Moran. I was alarmed to learn, from Mr. Moran's opening statement, that in Ireland we average 0.69 GPs per 1,000 population. Mr. Moran suggested that we require 1.1 GPs per 1,000 population. That is how needs are required in Ireland. The population here is based in rural areas, apart from some large cities. We need that kind of cover of GP practice if we are to provide a full service to our population. I wonder how we rank in relation to other European nations. Are we laggards or are we there or thereabouts compared with other nations in terms of standards?

Mr. Val Moran

According to the most recent OECD study, which I have seen, I think we are third bottom of that list, but comparing GP numbers across different jurisdictions is sometimes like comparing apples and oranges. We are towards the bottom of the table. England, as a comparator, would be up around the one GP per 1,000 mark and Scotland would be slightly higher than that. We are behind. There is also an issue with the distribution of GPs. For example, within a county there may be a 1:1,000 ratio, but in another county the ratio may be 0.55:1,000. It is the number of GPs and where they are that are the issues that need to be addressed. We are significantly behind the European average. It is sometimes difficult to know in terms of part-time workers, whole-time equivalents and issues like that.

Comparing jurisdictions can be difficult but on most of the measures, we would be behind the average.

I agree with Mr. Moran about county breakdowns. I live in south Clare, where there are a number of GP practices, but in the west of the county, resources are far more stretched.

There are out-of-hours GP support services, such as Shannondoc in the mid-west, which has been fantastic, and we have all availed of that out-of-hours support at one time or another. Coming out of Covid, have Shannondoc and equivalent services across the country sufficient firepower? As Deputies, particularly speaking as a Deputy from a Government party, is there more we can do to bolster that? As I have just referenced, people in west Clare and across the county lean very heavily on that out-of-hours service. Does more need to be done from a GP point of view to bolster that and give them more firepower or is the current position sufficient, coming out of Covid?

Mr. Val Moran

The GPs who work within and who are members of the co-ops are the ones who need to be supported. The GMS contract, which is what every GP works under, is a 24-7 contract and the out-of-hours obligation in that is discharged through the out-of-hours service. Sometimes, the GP will provide a shift but they are also in many cases paying for the red-eye shift, so they pay an amount to the co-op to hire a locum doctor to cover that shift. Obviously, we cannot have somebody working 24 hours a day so a locum doctor covers the red-eye shifts on a rota basis. However, that is a significant cost to those GPs. If there is something to be addressed, it is that there should be an overall review of the out-of-hours situation generally because it is not equitable across the country. There may be a very good set-up in Shannon or in County Clare but there may be a different set-up in another part of the country as they are all on different systems. A review would be timely from the GP point of view to ensure the rosters are equitable. The supports should go to the individual GPs who are supporting the co-ops and who are members of the co-ops. They are paying for the red-eye shifts in many cases and it is a cost to the practice for them to provide this cover.

I have a number of other questions, in particular for Dr. Quinlan and Dr. Crowley. As I should have said at the outset, collectively, GPs have done an incredible job in the past two years. There have been negatives, of course, and there were appointments that GPs were unable to fulfil because they were snowed under, which is not their fault and is a fact of the crisis we have been in. One of the positives has been how prescriptions have issued and how everything has moved very fluidly in that regard. Will some of those gains continue?

GP nurses have been fantastic. Much of the time when I go to my local GP practice, I do not even need to go into the doctor because the small-level stuff that I need can be adequately dealt with. This leads to huge fluidity. The State provides some subsidisation for GP practice nurses. I am curious as to whether there is standardisation of pay and conditions or is each practice the employer and sets its own terms.

With regard to GPs who train abroad, I did an Erasmus year study during college in the Czech Republic and I was amazed to find out there were eight or nine Irish students training to be doctors at the time and they are now all in the system, hopefully. Is the trend for them to come back home or do most of them stay and practice in continental Europe?

Dr. Diarmuid Quinlan

The Deputy touched on rural general practice. The ICGP is very supportive of this and we are co-hosting a global rural medicine conference in the University of Limerick in June of this year, so we are absolutely committed to it. I am also very conscious from my conversations with GPs in County Clare of how fragile the GP ecosystem is in Clare and the concerns about the retirement of one or two GPs in the more rural practices - no GP, no village. We share the Deputy’s concerns on that.

The Deputy asked about continuing the gains made during the pandemic. Electronic prescribing is fantastic, in particular for our patients. Just yesterday, I sent off a prescription for one of my patients who was at home in Cork. He rang me to ask could we send his prescription to his local pharmacy as he had gone back to college in Dublin, and I was able to email his prescription to a pharmacy in Dublin. This is bringing phenomenal benefits. Our colleague mentioned earlier how, given the right supports and encouragement, the HSE turned on electronic prescribing overnight, which was something we had been seeking for a long time. There are further benefits we can harness from electronic prescribing but it is certainly a great start.

In terms of whether we are going to maintain the benefits of the pandemic, the answer is absolutely “Yes”. One of the huge benefits we have had is that we have moved a lot of our education online. Twice a month, we have a webinar for in excess of 1,200 GPs and much of our GP education is delivered online, although, obviously, we have a blended approach because some of it needs to be face to face. We are absolutely committed to maintaining the benefits of the pandemic in terms of IT.

On the role of GP nurses, in my practice, with the assistant GPs we have one whole-time equivalent GP nurse. If we were in the UK, we would probably have between five or six and ten GP nurses. We absolutely need the resources to employ and upscale our GP nurses.

I might leave the terms and conditions issue to Mr. Moran because that is more within the remit of the IMO.

Dr. Tadhg Crowley

The Deputy made a point on the GP nurses. They are part of the GP team. We hear in hospitals about the consultants and their teams and we are now in a position where we talk about GP teams. These people who work with GPs in practices contribute hugely to the functioning of GP practices. We were talking earlier about allowing a general practice to change its subsidies to allow us to take on people, such as allied health professionals and healthcare assistants, depending on the area of need that we perceive is required for the practice. These will allow the GPs - the senior clinical decision-makers within our ecosystem, as Dr. Quinlan calls it - to make decisions that will be best for the patients. The nurses have employment contracts and we liaise closely with nursing unions and GP practice bodies on terms of employment but, ultimately, the GP is still the employer.

The Deputy made a great point on training abroad. He was abroad himself on Erasmus. I worked in Australia for a year and learned a huge amount about a different system and then came back and brought it with me. That has been the tradition for Ireland since time immemorial. The problem now is that the systems over there are very good to work in and people are not returning. That is a very important point. When we go back to the figures we had, of the GPs who go abroad, it is very hard to estimate prospectively how many people will stay abroad. In terms of the study that the ICGP trainees did in 2019, before they left 9% of them had already planned to go abroad and how many will return is a serious issue going forward.

If I have any speaking time left, I am happy for Mr. Moran to come in on some of the issues. However, I am finished with my questions. I thank all of the witnesses for their contributions. Like Deputy Lahart, I am a Government Deputy. We will digest all of this and if there is further information the witnesses can send us, we will certainly raise it in the right forum.

I understand Dr. Farrell wants to come in.

Dr. John Farrell

I thank the Deputy for his question. The ICGP and the IMO are hugely supportive of our practice nurse colleagues, who have really stepped up to the mark in delivering the vaccine programme and the booster programme over Christmas and the new year. They are wholly responsible in most practices for delivering all of the childhood vaccines, as well as dealing with women's health issues, cervical screening and chronic disease management programmes. General practice would be lost without them and we hugely value them. Obviously, the terms and conditions are up to each individual practice but we try to look after them as best we can because they are hugely valued members of the team. We need more of them in the general practice setting to provide the quality of care that we wish to provide.

I thank all of the witnesses for their comprehensive presentations. Hearing the issues with general practice and the workforce crisis being discussed has been an eye-opener. Many of my questions have already been asked and Senator Hoey touched a little on the issue of mental health. I want to ask questions on this. There is no doubt that a high-level working group to address all the issues relating to general practice is badly needed. It is vital having heard the presentations. It has to happen.

I want to speak about mental health. There are several areas I want to discuss. There have been many reports on the negative mental health impacts of the Covid-19 pandemic. I have seen the huge surge in mental health problems in general. It probably comes out of the whole trauma of Covid-19. The witnesses spoke a little about GP burnout. Are there supports that would help GPs in general in the work they do, bearing in mind we are in crisis with regard to the issues in general practice the witnesses have brought before the committee? Are there mental health supports for GPs given the amount of work they do and the threat of burnout?

Dr. John Farrell

I thank the Senator for the question. We are very aware that GPs have been under stress for a significant period of time. What are we doing to address this? More people are in group practices with peer support and peer review of work. This has been beneficial. We are conscious of the fact that 50% of our GP colleagues work in either one or two person practices. For many years, the college has had continuous education groups. These have been of huge help but they have been impacted by the pandemic. They comprise GPs who meet locally, often in a local building, to discuss clinical problems and get updated on what is new. They offer significant peer support for people under pressure in practice. They are able to discuss difficult cases and caseloads. They have been of huge value. They have been impacted by the pandemic but I hope, with the easing of restrictions, we will be able to get back to them. They have been in place for a significant number of years. They are greatly valued by our GP colleagues. They are one of the main ways for people to get support.

Dr. Rita Doyle has just stood down from her role as president of the Irish Medical Council. The IMC has been very aware of the pressures that doctors generally are under. There are support systems. The Irish College of General Practitioners has the doctors' health in practice programme run by Dr. Andrée Rochfort. It is accessed by colleagues when they are under pressure or in psychological distress and in need of a helping hand. No more than anyone else in the community, doctors are human. They have a significant workload and come under their own pressures. The college addresses this through various strands.

Dr. Tadhg Crowley

I thank the Senator for the question because it has been a very important question in recent years. I count myself as a middle-aged GP at this stage. I am learning about work-life balance from younger GPs. I am the first to say my work-life balance is atrocious at times. I am learning from what my younger colleagues expect and demand in terms of their mental health and their ability to stay longer in the job. This will impact on replacing GPs who are retiring. GPs are no longer willing to work the hours and other mad stuff that was done in the past and they are right. We can see the ill-effects that have been created in people in my generation. The hours that GPs work is another factor of the GP crisis.

I am hugely into sports. Huge numbers of GPs have got together in exercise groups, walking groups and running groups. This has been very important in Covid. I emphasise what Dr. Farrell has said about collegiality of GPs locally. It is always good to pick up the phone to speak to someone locally who understands the worries and concerns. When people are living in a community it is a bit difficult to speak to just anyone. They need to be able to speak to someone who understands what they are going through.

Dr. Diarmuid Quinlan

Dr. Crowley and Dr. Farrell have addressed some of the issues. With regard to burnout, we know that 40% of GPs have had great difficulty in securing a locum for sickness or holiday leave in the past two years. This is a substantial driver of personal burnout. Very good research from Ireland shows that for every two hours a GP consults patients, a further hidden one hour of non-patient-facing work is generated, including reading letters, writing referral letters, managing blood test results and making phone calls to hospitals and patients. There is a substantial hidden workload. My door seems to close at 6 p.m. but I will be there until 7.30 p.m. or 8 p.m. doing this hidden work. These are factors that contribute to the pressure in general practice.

Dr. Madeleine Ní Dhálaigh

I thank the Senator. With regard to what Dr. Quinlan said, when I started as a GP I did not regard anything that was not patient facing as work because it was hardwired into me that it was my job. Very quickly I realised that a huge proportion of my work was paperwork. Going back to what we said earlier, it is about support. We need to get in there before the GP gets burned out. Peer support and exercise are very important but we need to provide support to GPs before they get to the point where they are absolutely overloaded with work.

A point particular to women is that maternity leave cover is very difficult. We have good support for women who are partners to take maternity leave but the problem is accessing a locum. It is a huge stress in pregnancy for GPs not to know whether they will be able to take a week or full maternity leave. We have colleagues who went back to work much earlier than recommended for anybody else in any other place of work. This is something we really need to address for our female colleagues.

Another element is that many female colleagues who are planning families with their partners will be reluctant to take on partnerships for this very reason. They will stay as assistants because they know that as assistants they will be able to access maternity leave, even if it is unpaid. A practice may not be able to pay them because it will not be subsidised if they are assistants. There is a vicious cycle for women. It could be easily addressed if we supported women to get into partnership. It comes back to supporting our younger colleagues and they will deliver.

I want to ask another question with regard to mental health and Covid-19. I am sure GPs have seen more people coming to them with mental health issues, stress and anxiety. I am not speaking about extreme mental health issues. I am speaking about the everyday stresses of life that come with Covid-19. Is there a better way to equip GPs in managing this? Do some GPs have a mental health expert in their service? Is this something that could be looked at? If someone presents with a mental health issue of anxiety or stress, is there somewhere that person can go within the service or to whom they can be referred?

Dr. John Farrell

The pandemic has been very difficult for society. When this started back in March 2020, one of the significant difficulties was referrals. Everything was affected and a lot of people, particularly the elderly population, were very fearful of coming to see their GP. The number of face-to-face consultations reduced dramatically as we were encouraged to practise more online or on the telephone to triage problems that arose. Due to mental health services being underfunded and under-resourced for such a long time, GPs themselves deal with a huge number of mental health issues in general practice on a daily basis. That has become more obvious in the past 12 to 20 months with the pandemic. We manage a lot of it ourselves. We have access to counselling in primary care but as Dr. Quinlan alluded to earlier, sometimes that is not quick enough or readily accessible enough. Unfortunately, people who need counselling have to come up with their own funding to access that through private counsellors. Where those services are not available there have been increased referrals and self-referrals to emergency departments because people have not been able to access the necessary psychiatric care or acute psychiatric assessments. It is an issue. Through our educational webinar series we have tried to support GPs by providing education around mental health issues. That is something we have done from a practical point of view. In the main, GPs have been left on their own but we are used to that. We are the last generalists in dealing with all the different problems that present. Psychiatry and minor and major mental health issues are the bread and butter of general practice.

Mr. Val Moran

Regarding access to counselling services, the move under the GP agreement is towards community healthcare networks, which are small populations of approximately 50,000 people. There would be meetings between GPs and the network manager within that area to identify its needs. One area might need additional physiotherapy support whereas another might need counselling support so it is about trying to target those supports a lot more locally through that system. That is coming on stream through the GP agreement. It is not there yet but it is hoped that that will come on stream in the next year or so.

Dr. Madeleine Ní Dhálaigh

As I mentioned earlier, I am in practice in Castlerea, County Roscommon. Historically we had a very large psychiatric institution in the area so as a result of that there are a lot of healthcare workers in psychiatry living and working in the community, in the unit in Roscommon and in Ballinasloe. The problem with accessing care is that if people who have family working in the Roscommon service or any of the local services become unwell they may not want to go into that system. There is a problem with postcode psychiatric services and it is particularly problematic in rural areas as people who need very serious psychiatric care are unable to access it with any degree of privacy in the local hospital because of employment arrangements. This is something GPs have been talking about for a long time and it causes a lot of stress for the patient, their family and the GP. It is grossly unfair and does not affect any other area of medicine except psychiatry and, therefore, it must be looked at very seriously.

I thank all the witnesses. Hearing their presentations has been an eye-opener. There is no doubt about it. I agree that we need a high-level working group to look at the issues relating to general practice.

Unfortunately I have to run to the Seanad in the next few minutes. I first pay tribute to the GP community throughout the country for the role they have played in this pandemic, particularly in the roll-out of vaccines and the booster vaccine. If it was not for the significant role GPs and general practice played in general, that roll-out would not have been the success it is today.

Clearly, based on the figures Deputy Cullinane outlined earlier with regard to expected retirements and those going through the system, we are not going to have enough GPs over the next ten years. In fact, we will be down on the numbers we have now. What can be done in the short term to attract GPs from abroad who might be prepared to come to Ireland and locate here? What can we do immediately to make it attractive for GPs abroad to come and be employed in this country?

My second concern relates to the out-of-hours service. This is clearly an important service, particularly in rural areas where people are not as near emergency departments as they would be in Dublin or other cities. Some out-of-hours services are working very well and others are not. Clearly, funding is needed. Are the witnesses aware of examples internationally where out-of-hours services are working well? It is obviously a matter of resources but if there are lessons that can be learned or if there is an international model that we can emulate, we need to hear about it. I fully support the need to review the service because we need a system that is unified and that works in every part of the country, not just in some.

Dr. Diarmuid Quinlan

I am conscious of what Senator Hoey said about recruiting overseas doctors and that we need to be mindful that we do not impose a brain drain on low and middle income countries. The HSE has signed up to the WHO agreement on that. On recruiting GPs from overseas, the terms and conditions for coming here need to be attractive so we need to make it attractive for GPs to come. If they are attractive for overseas GPs they would be attractive for Irish GPs so we would need to address all the issues we have raised about the workforce and the workload capacity. In a nutshell, we need more GPs and GP nurses. We need the physical infrastructure, that is, the bricks and mortar, and we need the IT to support GPs to do their jobs.

On the out-of-hours service, I am on the Cork SouthDoc committee. General practice in Ireland delivers in excess of 1.3 million consultations per annum so it is extremely busy and we do a huge volume of work. I spoke to the manager of our local co-op in the past week in advance of this meeting. They identified the need for more GPs to support out-of-hours care so it is available across rural areas. We need more GPs and GP nurses to undertake appropriate activities within. It is essentially a manpower issue with the GP out-of-hours service as well.

Mr. Val Moran

The Senator asked about out-of-hours services in other jurisdictions. Ten years ago, England separated the daytime contract from the out-of-hours contracts and it caused a lot of difficulties. The out-of-hours service became a bit more corporatised with non-daytime GPs working within it and a lot of the work was just referred back to the daytime service. People also had difficulties with access. There are difficulties with out-of-hours services in all jurisdictions. A review is the first step to ensuring there is uniformity and equity for all GPs and the co-ops that they are a part of. It is not an easy problem and it is one that needs to be looked at but a review would be the starting point for that. There was a HSE review five or six years ago but I am not sure if it was ever published. It certainly needs to be looked at afresh now with regard to how the individual GP commits to that service and pays into it.

On attracting GPs from abroad, the things that will attract GPs from Ireland to take up positions are the same as those that will attract GPs from abroad. It is dependent on putting in place the incentives that we have spoken about.

Are there any statistics on the number of GPs who qualify in this country and go abroad? Are there any figures available relating to the GPs who graduated last year and the years before? How many of them stayed in the country and how many emigrated?

Mr. Fintan Foy

We undertake that analysis and research on an annual basis. The latest figures we have are for 2019, when 9% of the graduating class went overseas. I do not have the most up-to-date data but we can make those available to the Senator later.

That is okay. I suspect the figure would have been a lot higher than 9%. That figure is not too bad.

I thank the guests for their presentations and for all the work that continues to be done during the Covid pandemic. It was not easy for practices. There was an increased volume of work that had to be done. It has been much appreciated.

I was in the UK four years ago looking at GP practices. While there, we were advised that the practices we were looking had reduced the waiting time for seeing patients from 14 days to eight days. There was one practice that had 20,000 patients where all the GPs resigned on the same day. None of the adjoining practices would take on the 20,000 patients so the local hospital had to hire doctors to cover the needs of those patients. I hope we will never go down the road here where there would be a waiting time of 14 days for a person to access a GP. It is due to the commitment of GPs here that they have been able to provide a comprehensive service to their patients. Therefore, it is important that they get the additional supports to provide that service.

A number of people raised the inadequate number of support personnel, particularly nurses and care assistants. One of the challenges we will have is the availability of a sufficient number of trained nurses, even if we wanted to increase the number of nurses. Is there a proposal to train people as care assistants so that a sufficient number of people would be available within a short timeframe?

My second question is about primary care centres. The figures I have state that 127 primary care centres were built by 2019 - I do not have up-to-date figures - and at the time, there were another 70 in the pipeline. Is sufficient work being done on that, especially in major centres of population, to provide the necessary supports to GPs to come into primary care centres and, at the same time, on the co-ordination of other healthcare providers, such as physiotherapists, counsellors and all the support mechanisms needed in the community?

Dr. John Farrell

The Deputy made the point about comparison between Ireland and the UK and that in the NHS people were waiting for up to 14 days to see their GP. Unless it is for acute problems, which GPs will always manage and for which they provide a same-day service, the reality unfortunately is that for a lot of practices there is a waiting time of a couple of days to see a GP. It is down to capacity issues. The committee should also know that there is an increasing complexity of care in general practice. The days of very quick consultations are gone. With an ageing population, complex medical issues and multimorbidity, consultations are taking longer. With the advent of the chronic disease management programme, we are able to address some of those in a structured way, which is great. It goes back to the fact that there are capacity issues. If someone is acutely unwell, that person will certainly be seen and provided with a same-day service.

My practice moved into a primary care centre two years ago and it has provided us with ready access to ancillary services, physiotherapy, occupational therapy and our public health nursing colleagues. It is great and is one of the models of care but, going back to what Dr. Ní Dhálaigh and others said, it raises the questions of who owns the buildings, who pays the rent and who looks after the cost involved in providing the infrastructure. That is something we believe needs to be looked at also.

Dr. Tadhg Crowley

I will come in on primary care centres. I work in a primary care centre. It was a self-developed primary care centre whereby eight GPs came together in 2003-04 and got involved in the development of the centre. We learned an awful lot of what can go wrong and what will go wrong and we came out the other end. It is clear from what happened since that there will no longer be GPs self-developing, which is a pity. The Indecon report produced a number of findings which, if followed through, would result in GPs being willing to develop their own centres for the needs of their population.

In terms of the primary care centres developed by developers, they are now facing this situation of the rent, the property and the management. I get a lot of calls because we did our own centre. In speaking to a number of colleagues about ongoing management fees, one would definitely need a business degree to cope with some of the hidden snags that exist for GPs. Having listened to people's stories, GPs were burned. It worked out for us but there were other GPs for whom it did not work out. It has moved away from GP developers to developer-led primary care centres. There are issues in terms of how the payments occur. It goes back to what we were talking about before. I am sorry for taking up so much of the committee's time. We will have to look at the infrastructure for GPs and make allowances according to that. It is well worth looking at the Indecon report.

In fairness, there is a significant expense in getting a building up and running as well as equipping it. Is Dr. Crowley suggesting we should now look towards either the Department of Health or the HSE to become directly involved in providing the centres and then working with GPs?

Dr. Tadhg Crowley

I will go back to the first point I made about this. They are important but they are only buildings. We are in a primary care centre, but our ancillary staff are employed by the HSE. The HSE staff work from the building. They have their waiting lists. It is great to meet someone across the corridor and there are advantages, but they are still people experiencing pressures. It does not sort everything out. It is a great location to work from. It is handy for patients that they come to the same centre the whole time, but ultimately it is about people and our problem at the moment in the health service is a lack of people.

On the training of additional support staff, there will be a challenge in getting additional nurses because hospitals face that challenge. As such, GPs will also face that challenge. Is there a way of dealing with the provision of support staff who are adequately qualified to provide the support that GPs need? Do we need to develop a programme in this regard? Elderly care was referred to, for instance. We have approximately 740,000 people who are aged over 65 years and that figure will increase to 1 million in the next eight years. There will be increased challenges for GP practices and therefore they need more support.

Dr. Tadhg Crowley

I think absolutely, looking at the subsidies GPs get, if GP practices were given the facility for looking differently at it, we could look not only at getting nurses but at getting healthcare assistants in and, in some cases, buying hours of allied health professionals such as psychology and counselling. It would not take a whole lot to look at that and actually alter the way GPs work. What we can do at the moment is very prescriptive and it is a huge aspect of something that could be done in the next couple of months that would provide huge supports to GP practices to cope with the tsunami they are facing. I will not say that it is a quick fix.

I believe Dr. Quinlan wants to come in.

Dr. Diarmuid Quinlan

I thank the Deputy. I will follow up on Dr. Crowley and the role of GP nurses. As I said, we need substantially more nurses. Far be it from me to specify what nurses should be looking for but we need to engage with nurses and look at what terms and conditions they are looking for. We need a training pathway for young nurses when they graduate so that general practice becomes an attractive career for them. What steps do we need to put in place for that to happen? We need-----

I am sorry; can I stop Dr. Quinlan there? Is he saying there is not a training pathway in place at the moment for nursing?

Dr. Diarmuid Quinlan

General practice nursing is not recognised as a specialty within nursing. There is no structured career progression for them currently. They are at a stage where-----

I am sorry; whose remit would that come under? Would it come in under training colleges or under the-----

Dr. Diarmuid Quinlan

I think the nursing bodies would certainly have a really important role in developing practice nursing.

Okay. Has there been consultation with the various nursing bodies on that issue?

Dr. Diarmuid Quinlan

I am not aware of that.

Mr. Val Moran

Dealing with the healthcare assistant role is definitely something we see as being achievable and that can increase capacity. Certain defined tasks, which we have spoken about previously, such as ECGs and 24-hour blood pressure monitoring, are things a healthcare assistant could do that might free up a nurse or a doctor to do something else. That is certainly something we would like to look at.

With regard to practice nurses, people progress within practices and different practices have different set-ups around that. There is a level of progression within a practice. If a nurse is there over a period of years, obviously, that is different to somebody just coming in. There are salary and career progressions so there is a system of sorts in place.

I will go back over the issue about GPs and access to hospital services. One of the concerns that has been raised with me by GPs is the difficulty in getting access to support services. What can be done to try to improve that, in particular where a GP has a patient who needs urgent attention and is trying to get him or her through the hospital system? Does Mr. Moran think much more can be done on that in order that people can be dealt with? I know there were challenges over the past two years with Covid-19 but now we have moved away from that, what improvements can we achieve in that whole area?

Mr. Val Moran

I will make one point on that and I might defer to one of my clinical colleagues, Dr. Ní Dhálaigh or Dr. Crowley. The waiting lists are substantial and a significant amount of care is going to patients who are waiting on these lists. Even for something like a hip operation, that will be a six-month wait. The patient is in a lot of pain while he or she is waiting and being looked after within general practice and managing that pain. That is difficult for the patient and the GP. These are things that need to be looked at but I will pass on to Dr. Ní Dhalaigh to make a point on that.

Dr. Madeleine Ní Dhálaigh

It is really just to elaborate on what Mr. Moran said. A practical example would be that waiting lists have huge ramifications for people in the community and GPs providing care. As I mentioned earlier, if a person who is, say, a plumber, carpenter or in gainful employment has a sporting injury or otherwise at the weekend and comes into us with a cruciate ligament tear or some sort of injury that is going to impact their ability to continue their work and if they do not have private healthcare, they are looking at a two-year wait before they are even seen and given treatment. They are out of the workforce. It does not make any sense at any level and certainly on a human level, it is absolutely atrocious.

What we are doing as GPs is managing them by managing their pain and helping manage their disability if they cannot access physiotherapy in a timely manner. Our physiotherapist colleagues are excellent but there are just not enough of them. That adds a clinical burden on to GPs but it is also very difficult from an emotional labour point of view for GPs to have to witness this terrible bottleneck in the hospital system, which is not the fault of our hospital colleagues; it is the system's fault. A root-and-branch review of that has to happen.

Another example of this is our young scoliosis patients. Thankfully, I do not have anyone at the moment with that condition but I have GP colleagues who are absolutely at their wits' end trying to support these young people in pain who just cannot access timely care. It is awful. From a GP point of view, therefore, the professional and emotional labour from watching that and trying to manage it is immense.

Dr. Diarmuid Quinlan

What is really good and very much in the pipeline is that the HSE is currently developing community specialist clinics, which will substantially improve our access to our consultant colleagues. That is very much to be lauded. We also have limited access to virtual clinics, which will be really good for patients because essentially, it resources GPs and consultants to communicate directly without necessitating the patient travelling to the hospital, if we could build upon that.

Finally, another really good news story is that the HSE, ICGP and other key partners worked to get GP access to diagnostics, particularly MRI and CT scans. The preliminary reports outcome for that shows that giving GPs access to MRI and other radiology has reduced emergency department referrals by 74% for these patients and outpatient referrals by 85%. Giving GPs access to diagnostics and other supports, therefore, can substantially improve hospital waiting times, emergency department attendances and outpatient referrals. The HSE is doing a lot of good and we need to build upon this.

I will ask one final question with regard to GP connectivity with hospitals. I will give the example of someone who trained in obstetrics and gynaecology for nine years, decided it was not for them and then got involved in the GP training scheme. They have a huge amount of expertise yet they could not get hours in a hospital at the same time as working as a GP whereas in other countries, in particular, Canada, there is far more connectivity between GPs working in their practice but also doing some hours or days in the hospital. Does Dr. Quinlan believe this should be considered so there is connectivity? We seem to have drawn a clear line - a person is either out in the GP practice or in the hospital system but he or she cannot be between both.

Dr. Diarmuid Quinlan

We already have some of that. GPs are working across many hospital departments, certainly in my area. My concern at a strategic level is that I would not like to see that as a one-way flow of GPs going into the hospital and obviously coming back to general practice with very valuable skills.

I would also like to see the potential for young hospital doctors to come and spend more time working in general practice so we have a better shared understanding of each other's working lives and what patients come to us. It would work both ways.

Dr. John Farrell

One of my colleagues has a clinical post in a hospital but, as Dr. Quinlan said, we also need the flow in the other direction so that people understand what we do in general practice now in dealing with the complexity of care. There is not enough exposure at undergraduate or, indeed, postgraduate level to general practice in training and equipping our doctors. It has been shown and it was said earlier that if people have intern posts in general practices, they are more likely to pursue a career in general practice. There are only four or five posts in the country at the moment and the undergraduate exposure to general practice training is also pretty limited so we need to try to improve that.

Dr. Tadhg Crowley

Deputy Burke talked about staffing earlier. I hate to go back in history, but one of the fears about taking on staff is that when the FEMPI measures came in there were huge cuts to staff, which nearly paralysed a generation of GPs. I still hear colleagues say they are afraid to take on staff because we are still in that zone where it is difficult to do so because they may be cut again and we will have to let people go. Reducing wages paralysed staff. That is one of the other issues.

Does Dr. Quinlan have anything to add?

Dr. Diarmuid Quinlan

No.

I thank everyone for their contributions this morning. I very much appreciate it. I look forward to working with the witnesses in the coming years.

I have a few questions and I also wish to get clarification. Some of the members mentioned the Covid pandemic. For me, it highlighted the importance of having a medical system that works but also that delivers for citizens. The witnesses referred to 29 million consultations, 1 million of which take place in the evening. Society owes GPs a great debt.

The main focus of many of the questions has been on the retention and recruitment of GPs. A number of members, as well as witnesses, focused on the bricks and mortar or built infrastructure of GPs. The IMO referred to enhanced supports, including but not exclusively, tax relief, the funding of premises and so on. I seek clarification on that issue. What would be the opinion of witnesses on State-run GP services where practices are kitted out and staffed through the public service and GPs would be on contract with the HSE? Would that cause difficulty among members, in particular those who, as was outlined, are having difficulties with payment of services? First, it would reassure taxpayers that the money is going into those particular areas. The investment could be in areas of high deprivation or rural areas where there is clearly a shortage of GPs. Would that be too radical a plan, as part of the solution going forward? Perhaps someone could give a reply on that.

Mr. Val Moran

We had a little discussion on this earlier. The issue with having two different systems working side by side is that it makes it very difficult to do that. With regard to GPs working in rural areas and areas of deprivation, some strides have been made in recent years, in particular on the deprivation side under the IMO GP agreement where an additional amount of funding is going to the top 150 practices working in areas of deprivation. That has helped. There will be a further roll-out of that this year and a new system going in towards the end of the year that will help with deprivation.

On GPs in rural areas, we need to expand the supports that are available. They were agreed around ten years ago. There is a need to look at that and to support GPs in that area. I do not think the way to go is a system whereby we would publicly fund everything and the GP would work within it. The independent contractor model has given us the best of both the private and public systems. There is some entrepreneurial spirit among GPs, and we also have their clinical dedication to their patients. It is very hard to see how two separate systems would marry up with regard to the out-of-hours system. If they are employed, is it suddenly the case that paperwork currently being done in the evenings would no longer be done? How would it work? If certain services are provided on a fee-per-item basis in the existing system but not on a fee-per-item basis in the employed doctor system, will the employed doctor have an incentive to do these things? We have incentivised certain parts of care in the way it is set up. For the CDM programme, for example, the GP does two scheduled reviews per year and is paid a certain amount for that. An employed doctor is paid the same, regardless of what he or she does, so it is difficult to look at that.

There is a role for an employed doctor. It is already in general practice and it is working in existing GP surgeries. Once a number of doctors are finished their training, they may want to work as an employed GP for a number of years but after that, they may want to take on a practice in their own right. Even if there were an employed GP in a certain area, it is not the case that he or she would stay forever, which would mean that continuity of care would be suddenly lost. With the existing system, where GPs invest in the area and in practices, they are committing to the area and that helps with continuity of care.

In short, that is not a system we would look at because there would be too many difficulties with it. We have had reform overload in the health service and sometimes we need to improve the system we have to the greatest extent possible rather than going back to the drawing board because we would end up going backwards before we can go forwards and never get to the destination.

I understand the tensions that having two systems would create but doctors who are training would not need to concentrate on business and all the difficulties that arise in that regard. They would be able to get holidays and we would like to think there would be supports for them. It would be part of a solution.

What model would Mr. Moran like to see for GP services? Quite a few were mentioned, including different networks such as SouthDoc, TLC Doc in my area, Caredoc, Shannondoc and so on. They all seem to work with different structures. Would GPs like to see the system restructured State-wide or along existing lines with greater uniformity? Does the current system based on different approaches in different areas require greater clarity and uniformity of structure or are they happy with how it is developing?

On foreign doctors, it was mentioned that we are somewhat reliant on doctors from South Africa. Doctors from South Africa were unable to travel during the pandemic. There are different models in different areas. What is Mr. Moran's view of the structure?

Mr. Val Moran

It is not an easy situation. The co-ops grew up organically in each area, so they all have different systems. What would be best would be to review the situation, including all the stakeholders and individual co-ops, and look at the GPs who are working in the co-ops and funding them for red-eye shifts and the HSE. Everybody must look at this to ensure a better system is put in place for all the GPs working in the system. That would I hope be less onerous both in terms of the number of shifts and the financial cost to the individual GP. There is no easy solution to that. All the stakeholders must come around the table to come up with a solution everybody would agree is pragmatic. That would require a review, in consultation with all the different co-ops and the GPs working in them.

Does Mr. Moran agree that it would be helpful to have such a review of the system?

Mr. Val Moran

Yes. Without a doubt, there are issues with the system, so it needs to be looked at.

On an issue that was not discussed but which concerns the committee, how have GPs coped with the fall-out of the cyberattack? Are there any remaining difficulties in regard to that? We have had various people from the HSE before committee. Were there difficulties for GPs?

Are there lessons that we could learn? This comes back to supports in the form of IT equipment and so on. Are there ongoing difficulties?

Dr. John Farrell

I do not believe there are many great difficulties now. Matters have settled down but there was a great deal of difficulty at the time in trying to access records, communicate with hospitals and so on. There was then a question over what amount of data was missing when we got back online. From my experience, though, I do not believe there are difficulties currently. Matters are okay again.

Those were all my questions. Unfortunately, we have run out of time. I apologise to those who were trying to contribute. Working off a screen when chairing is difficult. If the various organisations would like to expand on some of the issues raised today or give greater clarity to any of the questions, we would be delighted if they wrote to the committee. I thank the witnesses for attending this meeting and for their contributions. They have been very helpful.

The joint committee adjourned at 12.31 p.m. until 9.30 a.m. on Wednesday, 2 February 2022.
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