JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 18 May 2006

General Practitioner Service: Presentation.

Chairman

This meeting is a discussion with officials from the Department of Health and Children and the Health Service Executive on the out-of-hours general practitioner service for north Dublin. I welcome Mr. Tadhg O'Brien, assistant national director for Dublin north-east; Mr. Pat O'Dowd, assistant national director for contracts; Mr. Sean McGuire, assistant to the chief executive officer of the HSE; and Mr. Fergal Goodman, principal officer in the Department of Health and Children.

Before the presentation commences, I draw the attention of officials to the fact members of the committee have absolute privilege but this privilege does not apply to witnesses appearing before the committee. Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. Mr. Goodman will begin the presentation followed by Mr. O'Brien.

Mr. Fergal Goodman

From the Department of Health and Children's point of view, I will set out concisely the policy context in which the co-operatives have developed and operate. My colleague, Mr. O'Brien, will go into some further detail on the north Dublin arrangements and what has taken place in the area.

General practitioner co-operatives provide the means for all patients, both medical card and private, to access appropriate GP medical care outside normal hours of service, including domiciliary visits, where deemed appropriate, by dialling a lo-call number. They also enable GPs to manage the provision of urgently needed care in a way which affords them a reasonable work-life balance. The development of GP co-operatives is in line with the overall policy strengthening primary care services and ensuring that, to the greatest extent possible, people's care needs are met in the primary care setting.

National policy is to support the further development of GP co-operatives in order that ultimately such services will be available to all the population. The putting in place of appropriate arrangements for large urban areas, including Dublin, is a particular priority of the Tánaiste.

With the establishment of the HSE, it is appropriate that the variety of different co-operative arrangements which have evolved over the years are reviewed with a view to ensuring that all the services meet appropriate standards of service and quality. This is being addressed by the HSE at present. It will also be a requirement, in the context of the review of GP contracts with the HSE for the delivery of publicly funded services, that doctors ensure patients covered by the contract can receive a service, as necessary, on a 24-hour basis.

The development of co-operatives began in 1999 in the then South Eastern Health Board and has moved on with further developments on an incremental basis in the intervening years. Out-of-hours co-operatives are now in place in all HSE areas providing coverage in all, or part, of all counties. It is estimated that more than 2 million people are covered by co-operatives and that additional funding provided in 2006 should allow for up to 350,000 additional persons to be covered.

Some of the co-operatives have put in place systems to monitor the satisfaction levels of patients using the service. In others, independent evaluations of users' experiences have been undertaken. These exercises have found high levels of patient satisfaction with the service.

The funding available to enable the development and operation of co-operatives has been progressively increased and, in 2006, the HSE's Vote includes approximately €33 million to support these services. Of that, €2 million is new funding this year which will translate to €4 million in a full year when the full year costs of this year's development need to be met. These amounts do not include patient fees paid to participating GPs under the General Medical Service, GMS. The funding is used to enable the establishment and operation of call answering services which also involve nurse triage and, where appropriate, the giving of advice to patients by telephone. Treatment centres are also operated and cars and drivers are in place to enable doctors reach patients safely and efficiently. Members will appreciate that is a significant consideration in rural areas, in particular.

I refer to work which is ongoing to provide GP out-of-hours services on a cross-Border basis. Work has been under way in the past year under the auspices of the CAWT organisation, a cross-Border health service group which aims to facilitate cross-Border health service initiatives. This project is in the area of GP out-of-hours services. The aim is to provide an additional service choice to people across the Border area who live closer to a GP out-of-hours centre in the other jurisdiction. A feasibility study carried out a number of years ago recommended the setting up of two pilot areas along the Border each with populations of approximately 13,000. One of the pilots will involve patients in the Republic accessing a centre in Northern Ireland while the other will involve patients in the North having access to a centre in the Republic. It would not involve domiciliary visits, so the GPs would continue to practice in their own jurisdiction.

The respective health departments, North and South, have met the CAWT team and the Health Service Executive to ensure any measures needed at Government level to enable this service to begin are addressed and resolved. It is planned that the service will commence later this year in the pilot areas. It will then be evaluated with a view to expanding that service arrangement further.

Mr. Tadhg O’Brien

North Dublin has a population of more than 500,000 with high levels of deprivation in certain areas. GP out-of-hours services in north Dublin are delivered through contractors who are commercially organised where GPs pay an annual fee to have their practices covered outside normal hours. Prior to August 2005, the HSE had been negotiating with local GPs to introduce a co-operative system which operates in many other parts of the country. As no agreement was forthcoming, the HSE made a decision to undertake a procurement process of enhanced urgent out-of-hours GP services for the population of north Dublin. The submission outlines the governance structure which we undertook comprising a steering group chaired by me and a procurement group chaired by Mr. O'Dowd. The role of the group is to undertake the procurement and make recommendations to the steering group. We sought tenders and we shortlisted and evaluated them. The procurement group evaluated tenders from two companies. In agreeing with the decision support methodology the procurement group established a minimum standard of 65% to be achieved by tenderers in both service offering and service capability. Following a series of meetings and a subsequent clarification, as no tender achieved the minimum standard, the steering group decided to terminate the tender process. As no party achieved the standard required, the chief executive officer, Professor Drumm, wrote to the IMO seeking its high level involvement in facilitating negotiations between the HSE and representatives of local general practitioners. For the past number of weeks, the HSE, IMO and local general practitioners have had intensive discussions regarding the problems involved. It has been acknowledged by all participants that significant progress has been achieved. A joint press release by the HSE and IMO confirms they are confident of a successful conclusion to these discussions within the next number of weeks and all parties expect the new comprehensive service to commence this September.

Deputy McManus

I welcome Mr. O'Brien and I also welcome the statement about the north Dublin position, which is a cause of some bewilderment. My understanding is general practitioners in north Dublin contacted the Department in 2004 and made efforts to provide a formal out-of-hours service. The Department went a different route, undertaking a tendering process that collapsed and we are back at square one again. Will Mr. O'Brien clarify whether that is a correction summation? It is curious that it has taken so long to reach a conclusion but I wish the negotiations well.

What percentage of the population is covered by a co-operative model? Is the objective to provide 100% through this model or will there be a mixture of co-operatives and individual doctors doing their own thing on an ad hoc basis? I am not clear on the ownership of the co-operatives. There will be a base and a triage nurse, for example. Who owns that? Perhaps Dr. McGuire can clarify that, given his considerable experience in this regard. I received reports that Caredoc was having difficulty obtaining funding. Will he also clarify the position on this? Does funding come through speedily so that it is not an issue or is there difficulty obtaining the funding on time?

I warmly welcome and support progress in providing such co-operative out-of-hours service because it is absolutely crucial. Compared with the hospital system, there are not many complaints about general practice. However, two regular complaints are made, one of which is the cost of a visit for people on low incomes and the other is out-of-hours cover where patients sometimes must wait for up to five hours for a doctor to call to their house and he or she is unfamiliar to the patient or they must attend the accident and emergency department. General practice is a vital component in the provision of health care.

There is a danger that people will think that because there is good out-of-hours cover, that will make a significant difference to the pressure on our accident and emergency department services. Even with good general practitioner cover at night, there will not be a significant change in the pressure on such services.

Mr. O’Brien

We deal with approximately 15,000 calls per week in all the HSE co-operatives, 40% of which are triaged by a nurse or doctor while 50% involve clients visiting the call centre and 10% are home visits.

Deputy McManus

Is it only 15,000 per week?

Mr. O’Brien

Yes, that amounts to approximately 1 million calls per year. I refer to how the service operates. A person rings a lo-call number, details are taken and the person is immediately called back by a nurse or a doctor. A total of 40% of calls are dealt with at that stage where advice is provided with which the client is happy. Meanwhile 50% of clients attend the call centre while 10% of clients receive a home visit, if required.

The co-operatives are State funded and, therefore, all the assets are owned by the HSE. In some co-operatives the employees are HSE staff while, in others, they are employed by the co-operative itself. The co-operative is a private company owned by the doctors but the assets are State-owned. The funding, as Mr. Goodman says, covers us. We received an additional €2 million this year, of which we will assign €500,000 to each area with a roll-out of €1 million per area in a full year. We will seek additional funding next year for areas not yet covered.

It is difficult to give a figure for the percentage of the population covered. Where a co-operative is in place, all the population in the area is covered.

The issue to which the Deputy refers is only one aspect of the accident and emergency department problem, which is multifaceted. However, co-operatives should prevent inappropriate attendances in north Dublin to such departments.

Dr. Sean McGuire

I am chairman of Caredoc and it has not encountered problems with obtaining funding. As Mr. O'Brien outlined, the structures of co-operatives can vary but the principles are the same. The company set up by the doctors in larger co-operatives is non-profit making and is similar in structure to a rugby club. The company employs all the staff and runs the entire show. Other facilities are run by the HSE and the doctors organise the clinical governance. Such a structure is envisaged for north Dublin whereby the general practitioners will be involved in organising the medical cover and the nurses will be an integral of this but the staffing and the provision and organisation of the service will be undertaken by the HSE.

The Deputy's point about the effect on accident and emergency department services is important. I was involved in setting up the first structured out-of-hours general practitioner co-operative in the UK and they have become the norm there. Prior to the new contract in the UK, which permits general practitioners to opt out of the out-of-hours service, it was pointed out that certain bits were missing that would have an effective interaction with the accident and emergency department. Ireland is still rolling out the structured out-of-hours general practitioner co-operative model. Over half of general practitioners in Ireland are now involved in this. Outside Dublin, probably close to 70% of general practitioners are involved in the structured out-of-hours model.

The element currently missing, as identified in the UK, is that there is no effective triage between accident and emergency departments and general practice out-of-hours systems. In other words, if we take the principle that ideally the patient should be seen in the most appropriate place by the most appropriate health care professional, patients who attend accident and emergency units who have conditions more appropriate to primary care would ideally be handled by a primary care health physician.

In some places outside Ireland there are structures in place whereby there is a triage mechanism between the accident and emergency department and the out-of-hours co-operatives. In the Dublin scenario, the co-operatives in the south of the city work for limited hours but are based in or close to accident and emergency departments. They would have this sort of relationship, whereby a patient who is more suited to primary care — in other words, a Manchester triage 4 or 5 — would be referred to the general practitioner and handled there. There is a high degree of satisfaction in that regard.

The other element is that quite a few patients bypass out-of-hours and in-hours general practice and go straight to accident and emergency units. We must ask why this happens. In many cases, the reason it happens — studies have shown this — is that patients perceive they need an X-ray. In general in Ireland, general practices have no access or poor access to simple X-ray facilities or ultrasound scans. The HSE is addressing this as a matter of urgency and €3 million will be spent by the end of the year on purchasing the facility for general practitioners to access plain X-ray and ultrasound. In the out-of-hours setting, the natural progression must be that general practitioners will have access to those diagnostics. One would then expect this to have a significant impact on the number of patients attending accident and emergency units.

Senator Henry

I welcome the representatives from the Department and the HSE. On the north Dublin co-operative, why did the tenders fail? Was it because of capacity? I was told it was because enough doctors did not express an interest. When Professor Drumm spoke to this committee he said a number of young general practitioners, women in particular, wanted to start lists in the area, but there appeared to be a reason they could not do so. It is a serious matter if it is not possible for people willing to work in the area and to become involved in co-operatives to do so.

I agree with Deputy McManus that the co-operatives will make little difference to the trolley situation in accident and emergency units because those on trolleys are people who need admission to the hospital. Where the co-ops would make a difference would be if the general practitioners involved in them had the rights they had up to approximately ten years ago to send people such as those with a stroke, acute appendicitis etc. straight to the relevant department of the hospital rather than to accident and emergency units. The current system of sending them to accident and emergency units is a ridiculous waste of time and money and possibly endangers the patient's health by delaying treatment.

We have known for decades about the situation regarding inappropriate attendance at accident and emergency units because patients think they need radiology. General practitioners had better access when I worked in casualty almost 40 years ago than they have now. How has this dreadful situation been allowed develop and what will be done to rectify it? For the past 20 years I have been hearing that it will be rectified, but this has not happened. The situation has got worse, particularly recently.

Has the belated opening of the Ballymun health centre made any difference to attendances at the Mater or Beaumont?

Mr. O’Brien

The reason the tenders failed was due to quality. Neither party could guarantee that the doctors employed would be members of the Irish College of General Practitioners or would have three years general practice experience. We laid heavy emphasis on that criterion.

When I spoke about inappropriate attendance, I was referring to the fact that if people in north Dublin are unable to contact a general practitioner, they attend accident and emergency units.

The Ballymun health centre opened recently, but we have no data on it yet. The public are delighted with the quality of the building compared with what they were used to. We hope the centre will be used by the out-of-hours service when it is set up.

Senator Henry

I also asked about access for general practitioners.

Dr. McGuire

I agree with what Deputy Henry has said. On what is being done about access, a specific sub-group was set up to examine the issue. As an immediate response, the funding I mentioned has been made available to provide general practitioners in the areas with the greatest need — the longest waiting lists — with access to plain X-ray and ultrasound. From next year, Professor Drumm's emphasis is for the reorientation of the health care system towards primary care in the community.

I do not know what has been happening in the past 20 years, but I imagine that, as has happened in most health care systems in the world, people have been putting resources into the acute sector and ignoring the fact that 95% of health care is provided in the community. Professor Drumm is now doing what has been done internationally by any country which has significantly reorganised its health care system. These have put the emphasis on building up services in the community so that when patients become ill, the first place they look for help is within the community, not the hospital.

It is therefore a priority to provide access for diagnostics to general practices. There are three elements to this development. First, we must consider the extension to the working day in hospitals to ensure capacity is maximised. The infrastructure is already in place but we need personnel and to extend the working day. Second, we must build up services within the community. We know there are many community hospitals throughout the country. Ballymun health centre was mentioned. The intention is that Ballymun and other community care centres will have X-ray facilities. With modern technology such as PACS, the results could be beamed to the local hospital. I am a general practitioner in Carlow and we have a service whereby I can have my patient X-rayed, but the X-ray will be read in Kilkenny. Third, we must consider using the private sector, either existing private hospitals or the potential for the provision of elements such as community diagnostic centres. These three elements must be explored.

I agree entirely with the final point raised by the Senator regarding the effect of patients on trolleys. However, many areas are being actively explored at present by the HSE. We know that a significant number of these patients on trolleys could be managed within the community if the appropriate services were available. Community intervention teams are starting next week in Cork and they will cover all of Cork city. This scheme will be extended to Dublin and Limerick.

Community intervention teams will remove the necessity for GPs and people in accident and emergency departments to arrange for the admission of patients because of social needs. This means there will be a rapid response to deal with the needs of a person with an acute illness which can be managed in the community but who requires home support. We hope to have in place by this winter facilities to expand the management of, for example, community-acquired pneumonias that could be appropriately treated in the community with access to intravenous therapy. There are ways in which those services can be provided in the community and they are also being explored.

Deputy Connolly

North Dublin is part of the same health region as my own area, stretching as it does from the River Liffey to Blacklion in County Cavan. I welcome the developments taking place in the region, though I suppose it will be September before they come on stream. I hope these developments will take a lot of the pressure off the accident and emergency departments in Dublin.

What plans are in place to provide diagnostics and intravenous therapies in these GP centres and when will they be in place? I ask the delegation to expand on this topic. Reports from the Health Service Executive about the out-of-hours GP service always state that the rate of patient satisfaction is high. However, I must be meeting the wrong people. I have heard much dissatisfaction expressed about the length of time it takes to get a doctor and the panic and desperation this causes in homes. Is it the case that people are afraid to say they are not satisfied with the GP service because any form or hint of complaint might impact on their future treatment? There is this perception to a fair extent.

In my area the GP centre is located in Castleblayney. The further removed one is from the centre, the move difficult it appears to be to get a doctor to make a home visit. They will do a lot at the level of triage and ask many questions but very often an individual in a remote location will not gain access to these GPs. I suggest that when a survey is conducted, it should follow up on whether the service was adequate for the patient. I hear regular complaints about availability. I like the concept that a doctor is available and I would like to see the service being developed whereby patients could have an X-ray taken or be given intravenous therapy. This is the way it must move. However, I am concerned about these people in rural locations who are far removed from the centre and who do not get a service.

I refer to the pilot projects in the Keady-Armagh and Castleblayney area and in the Donegal area. I am not aware of the length of time these pilot projects have been running but many people living in Border areas would like a seamless service where patients could access a service in Emyvale or Aughnacloy or Clones or Newtownbutler. This is the policy that would work best for the rural population in those areas and it is the only way forward. I ask the delegation to explain how those pilot projects are working and the timescale for their roll out to the entire Border area.

Many people would be more than happy to use an accident and emergency department in Monaghan if they were in the Middletown, Aughnacloy, Rosslea areas and were suffering from a heart attack. Are there any plans in place to allow for an ambulance to be sent from one side of the Border to the other? We are all aware that minutes matter in the case of a heart attack and people are very fearful about what would happen if they had a heart attack, a haemorrhage or a stroke.

Reference was made to a total of 16,000 people a week making contact with the service. This is a lot of people and I suggest heavy demand is concentrated on GPs at the weekends. What volume of patients could a GP centre with a GP on call adequately cover? How many GPs will be available to cover the half a million people in north Dublin?

Senator Browne

I welcome the delegation. Is it correct to assume that there is a significant shortage of GPs in the country? I am aware that in Carlow town it is next to impossible to get on the books of a GP practice as a new patient. It is all very well for the Tánaiste and the Taoiseach to talk about a change in the hours worked by doctors, but doctors are human beings who are entitled to work a certain number of hours per week just like any other worker. I would not be confident to go to a doctor who has been working 12 hours in one day as they could make mistakes in a diagnosis. Issues of safety are raised by these working hours. Doctors cannot be expected to work from 8 a.m. until midnight and be blamed when a mistake occurs. We need to recruit far more GPs.

How many of the current trainee doctors are non-nationals who have no intention of staying here once qualified? How many more GPs are required, considering the population has increased by half a million and people are living longer? People are healthier and it is possible to survive a heart attack which would have killed them in past times. The advent of bypass surgery means people are surviving longer and they are also surviving prostate cancer. Hip and knee replacement operations are commonplace. This longevity puts more pressure on the health services.

Caredoc was founded in Carlow and has been a great success. Has any customer survey been carried out on the Caredoc services? Like Deputy Connolly I have heard many good stories about Caredoc but also some bad stories. A comprehensive survey of the service would be in the interest of the doctors. My sister availed of the service recently and she was very satisfied with it.

I wish to ask about elderly people and instance the case of an elderly couple where one of them is the driver. When that person becomes too old to drive, they find themselves marooned and must pay for taxis to visit the doctor. This can be a deterrent to visiting the doctor. Doctors seem to be phasing out house visits and this will have an impact on elderly people who may not have family members to bring them to the doctor's surgery. This is a big problem for an ageing population.

Dr. McGuire referred to an X-ray service. In Carlow it can take up to five days for X-rays to be read even though broadband is now available. I do not know why it cannot be done straightaway.

I would like to speak about Caredoc. No doctors are on duty on Wednesday afternoons in a town in County Carlow. Problems arise because, as I understand it, Caredoc does not come into effect until 6 p.m. There can be a gap in service at certain times. Perhaps that is a specific case. Out-of-hours care services might not cover every set of circumstances. We need far more general practitioners. We cannot expect GPs to work unreasonable hours.

Mr. O’Brien

I will reply to Deputy Connolly, who spoke about the north-east area of the Health Service Executive. One in every ten patients in that area is surveyed. A constant satisfaction rate of over 90% has been determined on foot of the detailed questionnaires which are sent to the people in question. The Deputy asked about the circumstances in Clones and Emyvale. One of the benefits of the co-operative in his area is the availability of general practitioners during the day. We used to have to advertise for GPs in Clones every six months when they kept leaving because they were working on an onerous rota. We have not had any vacancies since the north-east doc scheme was introduced in Clones. One of the benefits of co-operatives is that they enable doctors to work and practice from small towns. They have proved to be successful in ensuring that doctors are in place during the day throughout the country.

I was also asked about the co-operation and working together project, which has not yet started. There are problems with registration in the North of Ireland under the new contracts which are in place there. We met representatives of the Northern Ireland Department of Health, Social Services and Public Safety last week and they told us they are hoping to change the regulations to allow patients from Keady to be seen in Castleblayney. It is planned that the pilot programmes will involve Keady and Castleblayney, and Inishowen and Derry. It is hoped that the system will be extended to cover the 1 million people who live near the Border, on either side, following an evaluation of those programmes. For example, people living in Carlingford have easy access to Newry. The ambulance service links with co-operatives all the time. If an ambulance is necessary, the co-operative gets one to come. We will look at the cross-Border element of that when the full roll-out of the cross-Border out-of-hours service has taken place. We hope to have four or five centres in strategic parts of Dublin, such as the city centre, Ballymun, Swords and Coolock. House visits are determined by the doctor on call on the basis of the patient's medical need. I ask Dr. McGuire to respond to the question about diagnostics.

Dr. McGuire

The delay in reading diagnostics is a valid point. There is no point in making diagnostics available to general practitioners if they then have to endure delays while waiting for the reports. Professor Drumm has highlighted the importance of cross-appointments in this regard. When consultant radiologists, for example, are appointed, specific sessions will be dedicated to the community. Traditionally, consultants have been appointed in the hospitals sector and their jobs have generally related to what takes place within the four walls of the hospital. I accept that there are some community paediatricians and geriatricians. The delay in reading diagnostics is not a technology problem, it is a human issue.

I reiterate what has been said about the concerns in respect of patient evaluation. The normal pattern in co-operatives is that letters are routinely sent to one tenth of all patients. As such letters are automatically generated by computers, patients are not selected by any person. The questionnaire that is used — the McKinsey questionnaire — was chosen on the basis of best international practice. It asks about patients' satisfaction with the length of time they were waiting and with those who took their calls and with whom they were in contact.

We were also asked about delays. Response times, which comprise a crucial part of the assessment of co-operatives, are considered on the basis of the medical need of patients after they have been triaged. People in the community, particularly elderly people, have valid concerns. A system has been put in place in an organised co-operative setting. If patients have concerns about their particular cases, that information can be put on the system to ensure it will flash up when they telephone. If a patient has concerns about a medical problem, an allergy or even a terminal illness, that information can be put on the system. Information about how to get to a patient's house, which is quite important in rural areas, can also be placed on the system. Such issues are being addressed.

A question was asked about numbers of general practitioners. The figures for Ireland do not vary much from the figures in the UK and other countries. The out-of-hours call rate is between four and six calls per 1,000 people covered. An average of five calls per 1,000 people would mean that the authorities in north Dublin could expect between 2,000 and 3,000 calls to be made over the course of a week. We know that between 30% and 40% of those who call are just looking for advice. In such cases, patients are happy that they are just ringing up for advice. It is one of the elements of the out-of-hours service with which patients are most satisfied. Before this system was put in place, patients were concerned about ringing a doctor at 3 a.m. because they knew they would be contacting a doctor who was at home in bed. When they contact out-of-hours co-operatives, however, they know nurses are usually available to be telephoned at any time. One would expect approximately six doctors to be on duty in north Dublin to cover its population. That is the plan. The most important thing is that they are based in centres. Patients can go to centres instead of relying on doctors coming to them in cars, which is an inefficient way of doing business. It was suggested that no doctors are available in Carlow on Wednesdays. Some doctors in Carlow and many other parts of the country will take——

Senator Browne

I am talking about one particular area.

Dr. McGuire

Yes. I thought the Senator was referring to Carlow town.

Senator Browne

No, I was not referring to Carlow town.

Dr. McGuire

That is why I was a little surprised.

Senator Browne

It is a localised problem. It is not necessarily a Caredoc problem.

Dr. McGuire

General practitioners work out-of-hours as well as in-hours. Most doctors generally aim to have a half day off during the week. They usually arrange for cross-cover with their colleagues at that time. Mr. Goodman might speak about issues relating to the number of GPs. There is a problem in getting GPs. There can be difficulties for GPs in getting doctors to cover for them during their holidays. That problem is related to many issues such as medical education. The number of training places is being increased. Most importantly, it is something that will be addressed in GP contracts. Under the current GMS contract, GPs have to sign up to take responsibility 24 hours a day, seven days a week, 365 days a year. The increase in demand for family-friendly services is a critical issue that will be addressed in the GP contract. An attempt will be made to make it much more flexible. For example, the contract will facilitate groups of doctors who wish to come together to take joint responsibility. They will, therefore, incorporate part-time working and flexibility. This will have a significant impact because we know that, for the past decade, the majority of doctors qualifying from vocational training schemes are female. However, the actual gender balance among principals in general practice does not reflect this. This means that many of the doctors completing training are not taking up GMS contracts and entering full-time practice. One of the many reasons for this is the onerous contract currently on offer. The second reason has been the onerous demand on providing out-of-hours services. The roll-out of co-operatives will be one of the best ways of ensuring the survival of rural general practice.

Senator Browne

Are more general practitioners needed?

Dr. McGuire

Yes.

Senator Feeney

I welcome the delegation. Dr. Gary Courtney of St. Luke's Hospital, Kilkenny, has been highly praised in recent years for his success at the interface between general practice and accident and emergency medicine. Dr. Courtney was interviewed on the "Prime Time Investigates" programme broadcast earlier this week. Does Mr. McGuire believe the type of system in operation at St. Luke's Hospital could serve as a blueprint for the relationship between general practice and accident and emergency departments throughout the country?

On an issue raised by Senator Henry, a delegation of accident and emergency consultants informed the joint committee that a patient attending an accident and emergency unit with, for example, a broken toe would be seen by five different personnel before being seen by a consultant who would sign off on the patient. Senator Henry praised the old system in which one visited one's general practitioner who would write a letter outlining his diagnosis. The patient would then bring this letter to hospital where he or she would go directly to a ward. Times have changed, however, and under the current system a patient will be seen by an experienced general practitioner before visiting an accident and emergency department in which he or she will be seen by several junior hospital doctors who are prevented from taking a decision on admission or discharge because this is a matter for a senior consultant. Surely this undermines general practitioners to some degree.

Given that hospitals do not provide out-of-hours diagnostic services, it is somewhat premature to propose providing them at community level. It would help the community, however, if they were available in hospitals.

Senator Browne referred to a case involving X-rays not being examined for five days. We in Sligo are pleased that a digital X-ray system, known as PACS, is being introduced in the local general hospital. I read with interest that two out-of-hospital, community-based facilities linked to the new service will become available in Carrick-on-Shannon and south Donegal, respectively. The €3.5 million cost of the project is a small amount in the context of the health budget. Similar schemes should be considered for other areas.

One would be obliged to search far and wide to hear someone complain about a general practitioner because they are, by and large, respected and held in high regard by their patients. I agree with Deputy Connolly, however, that some people are a little afraid to speak out because we tend to have such close personal relationships with our GPs, who are our first port of call. For example, I would never consider visiting an accident and emergency department without first consulting my general practitioner. People have informed me that they find it difficult to get their GP to come on a house visit when they fall sick because most of them operate walk-in or appointment-only surgeries. Middle aged and older patients cannot decide to make an appointment a week in an advance of becoming sick. Is this a product of the times in which we live? Is it the new model for general practice? Gone are the days when one telephoned one's local GP to tell him or her one would soon arrive, either in person or with a relative. Will Dr. McGuire comment?

The presentation indicated that community diagnostics would be delivered through the private sector. Where does the public sector fit in to this? The presentation also indicated that tenders had to achieve a minimum standard of 65% for service offering and capability and that the tender process was terminated because none of the tenders reached this magic figure. How was this percentage determined? It appears to be relatively low as would expect that a 100% service offering and capability would be required?

Senator Glynn

I welcome the delegation and apologise for being late. I have a deep interest in out-of-hours GP services and acknowledge the great work done by Mr. Pat O'Dowd, the former deputy CEO of what was the Midland Health Board, when he led the charge on out-of-hour GP services in counties Longford, Westmeath, Laois and Offaly. The service in the region has been a tremendous success.

The statement sets out in simple terms where the difficulties with the tender arose. The Health Service Executive simply could not find people of the required standard to provide the service. Senator Browne who, unfortunately, was obliged to leave the meeting asked a pertinent question regarding the number of general practitioners available. The Fottrell report, which was recently adopted by Cabinet, contains a proposal to lift the cap, which dates back to the 1970s, on the numbers of those entering medical school. The latter is a positive step but it will take several years for its benefits to emerge.

Senator Feeney is correct on the question of 65% coverage. It proves that the applicants could not achieve the minimum standard of 65%, which, by any standards, is not difficult to achieve. Given the type of service involved, the threshold was very generous and it speaks volumes that the applicants could not reach it.

I missed the discussion on existing GPs. What is the involvement of the area's general practitioners in the service? Are all of them on board? The involvement of local GPs was pivotal to the setting up of the MidDoc service in County Westmeath. A number of GPs there worked feverishly to establish what has become tremendous service.

On the training of doctors, are there any plans for those in training to become involved in the out-of-hours service? When an individual qualifies as a GP, the out-of-hours service will provide a different experience in a different area of service. I am glad Deputies Fitzpatrick and Twomey, who are doctors, are present because they may be able to throw some light on the matter. Dr. McGuire might be able to do so also. Would it not be beneficial to have people in training for medicine involved with those teams? I believe it would be of great value but perhaps the system does not work that way.

I have been giving out for a long time about the phenomenon of people bypassing their local GPs. It is one reason our accident and emergency departments are clogged up. Many believe going to accident and emergency departments is a cheaper option. When one walks into an accident and emergency department, one sees people presenting with complaints that could be dealt with adequately by a GP in his or her surgery.

I am delighted there will be cross-Border co-operation, which makes great sense. The first facility I visited in this regard as a member of the former Midland Health Board was in Ardee and I was very impressed by it. This was prior to the setting up of the MidDoc service. As a result of the success of the facility, one was set up in my area. We must acknowledge that the then Minister for Health and Children, Deputy Martin, provided the necessary funding.

Deputy Twomey

I thank the delegates, who have a good range of experience in respect of co-operatives. I have direct experience of working with Dr. McGuire regarding the Caredoc scheme in the south east. My colleagues on this committee have very high standards and seek far more than 65% when evaluating tender documents.

The tender documents have never been published, nor has the evaluation. Members would appreciate if they could be sent the tender documents and a more detailed idea of how the evaluation was carried out. I read the documentation pertaining to the awarding criteria and it states that project management includes evidence of project management, methodology, including time lines, resources, deliverability and integration of service components. To be honest, this does not mean much to us because we need to see what the evaluation process involves.

This issue is very important to members because prior to the issuing of the tendering document, there were negotiations with the HSE regarding setting up the out-of-hours co-operative with the local GPs. These proceeded for a number of months and then collapsed. The local GPs were very angry and there were a number of accusations made by both sides regarding what was being offered, or not, by the GPs prior to the tendering process. We should be quite clear on the difficulties encountered.

The tendering process was advanced but we have no idea of the criteria. It was stated that there should be members of the ICGP with three years' experience. The tendering process collapsed and the Department and the HSE were not happy with what the two remaining groups had to offer. One group consisted of local GPs and the other was a private outfit. Now the HSE has gone back to the local GPs seeking to negotiate with them to establish the co-operative. These GPs are the same people who were not regarded as good enough in the tendering document or prior to the tendering process. What has changed given that we are dealing with the same group that featured when the process first begun? How does the existing level of service compare and what changes are the doctors expected to make if they are to become involved in the out-of-hours co-operative?

I have very little respect for the deputising service because the quality of the patient care is far too variable. One can be very lucky and get a good doctor or be very unlucky and get one with little or no experience. I have encountered doctors who were not sufficiently happy about making a decision on a sick child and wanted an independent evaluation, which they obtained through the deputising service. However, they were shocked with the level of experience of some of the doctors in the service. The best way forward is to use fully trained GPs, which is what is now being done.

This committee is wondering what is wrong now and what was wrong prior to the tendering process. We need to see the tendering documents and a more detailed evaluation than the one received in this presentation. We want to know what the HSE is now negotiating with the doctors. This is a very significant issue involving 500,000 people and a great number of doctors. We need greater clarity, which is what we sought in the presentation. This issue has been pertinent for over a year and it is almost a year to this day since the GPs in north Dublin first advanced proposals to establish a co-operative, yet we are still at the exact same point of negotiation. Professor Drumm has made announcements that the initiative will commence by 1 September. I said yesterday to the Minister — Dr. McGuire will agree — that we had the money from the Department and the agreement of the doctors. It just involved an extension of Caredoc, yet it took four months to organise the rota, buy the cars and establish the centres. It is therefore unrealistic to expect the service to be running by 1 September, but I may be wrong.

Deputy Fitzpatrick

Are the standards demanded for the north city out-of-hours co-operative higher than those demanded for other co-operatives around the country? Who will supply the backup and the premises? Have the locations of the co-operatives been decided?

Mr. Goodman

A number of members of the committee referred to the GP manpower issue. Let me amalgamate the questions and respond. The issue is multifaceted because, as members have said, one must consider the initial training of the GPs and then their specialist training. One must consider how the current contractual arrangements operate in terms of facilitating the available GP manpower involved in the delivery of service.

On the question of initial training, the Fottrell report has moved us towards providing additional medical training places and the Government has decided to fund them. Funding has been provided for GP training over the past two years and there is additional funding to increase, on a phased basis, the number of GP training places from 84 to 150. This is the second of three years in which we are aiming to establish additional places. In parallel with this, we want to consider, in a more strategic and long-term way, the GP manpower needs, taking on board the future demographic trends affecting the GP workforce and the population. The aim in respect of service development, to which Dr. McGuire referred, is to provide for the vast majority of people's care needs through primary care. This obviously involves an additional requirement for GPs and we will therefore be considering, in a structured way, how to draw all these issues together and plan for the filling of the necessary training places.

As Dr. McGuire stated, the GP contract under the GMS is somewhat restrictive in that it requires the provision of the service to a given population. This contrasts with a system under which every available GP would be able to hold a GMS contract. In the ongoing contractual review, we hope to address access by available GPs who do not have a GMS contract but want one.

As Dr. McGuire said, at the moment the GP is the sole contract holder and is obliged to ensure the full service is delivered to the GMS client. We would like to see more flexible arrangements which would enable more family-friendly arrangements for the GPs while facilitating more extended hours of service. Arrangements that would permit GPs to group together to service the contractual requirement on a 24-hour basis would allow us to attempt to match the available manpower to the service we want to deliver in the most effective way. At the moment there are blockages and restrictions in the system that mean we are not getting the best possible use of the available manpower.

Mr. O’Brien

I was involved in the tender process. We started discussions on this last year and the same answer as I gave earlier applied — we could not achieve the desired quality. We could not get guarantees that the GPs involved would be members of the Irish College of General Practitioners or would have three years general practice experience. We made a decision at management to go to tender but the tender did not work out and we did not achieve the standard we require.

Following discussions and a letter to the CEO of the IMO, we have had intensive negotiations and it has been acknowledged by all participants that significant progress has been made. The IMO has facilitated the dialogue between the HSE and local GPs. Our press statement indicates — we are confident of this — a successful conclusion in the coming weeks with a view to starting in September. We hope to be quicker than the model described because all the backup cars, drivers and nurses will be owned and run by the HSE; all we need then is the doctors to form the roster. Every other part of the business will be carried out by my staff.

Mr. Pat O’Dowd

We had to operate in accordance with the standard procurement policy and procedures of the HSE and within that was the negotiation process. There were stages to go through with the prospective tenderers, one of which was to allow them to submit their tender documentation and then present how they would deliver the service. We set a standard of 65% but it is not a simple 65% on a path of zero to 100%, it was a matrix of a number of indicators of standards of quality and was meant to be a baseline position where we could decide if a company reached that level or exceeded it and we could then bring them to the next stage, a more detailed process of negotiation. Through that process deficiencies in the submission would then be identified and we would see if we could negotiate an enhancement and improvement in elements of it. The 65% was a baseline figure to get people into a more intensive negotiation process rather than the be all and end all for the contract to be awarded.

The standards used are essentially those employed across other co-operatives, particularly ICGP standards in terms of qualifications of the locums, which has been alluded to already. Companies had to meet the 65% baseline before we could engage in more detailed negotiation through which there would be an opportunity to enhance deficiencies.

Dr. McGuire

It is worth saying a few things about the establishment of out-of-hours co-operatives and how, in reality, north Dublin is no different from most other places.

The commencement of an out-of-hours GP co-operative involves significant change in the way GPs work. We are talking about doctors who are already working during the day, and outside Dublin one of the driving forces for GPs to get involved in co-operatives is how hard they work during the day. Traditionally doctors had to work every third night and every third weekend, as Deputy Twomey would know personally. A major driving force has been the improved lifestyle for the GP and his or her family. Despite that significant benefit, GPs around the country often take a long time to come round to being based in a treatment centre rather than at home when they are on call, a major change.

In north Dublin, there is a large number of hard working, high quality GPs. The difficulty of getting GPs around the country has been mentioned and this is particularly highlighted in north Dublin where there is the largest GMS list and population per GP. Those are issues that the HSE must address to support GPs. Despite that, there are GPs doing tremendous work. Until the move into the Ballymun centre, the GPs and the rest of the primary care team worked in abominable circumstances in an area where there are high levels of deprivation, but the quality of care they provided for the patient population was of the highest standard.

In north Dublin, traditionally, these GPs are under tremendous pressure during the day and had a service to cover out of hours where the concerns expressed by Deputy Twomey about standards would be shared by many people. That service has not moved with the times. Society has changed so much in recent years that the days when a patient only contacted the doctor out of hours when he was very ill are gone. People are now used to shopping on a Sunday. Therefore, the threshold for contacting the doctor on a Sunday has been lowered. The demand for out-of-hours treatment has escalated internationally. If we take an average contact of five calls per 1,000 population covered out of hours in Ireland there would be 1 million contacts per year. Currently, within hours, GPs handle 15 million consultations per year. In the context of the acute sector and the number of patients attending accident and emergency units, general practice dwarfs what is happening in those settings. We will not go over the fact that GPs have been hampered by not having the necessary tools, such as diagnostics, which the HSE is now addressing as a matter of urgency. In north Dublin, there is a group of GPs who traditionally have had the support of an out-of-hours service while they themselves are under tremendous pressure in-hours. Establishing the system has taken some time in other areas. Deputy Twomey was involved in the establishment of the extension of Caredoc to the south east. He knows that prior to the funding being made available, there were pockets of GPs who were reluctant for their own reasons, particularly their concerns for patient care, about joining the service. These GPs would get tremendous improvement in their out-of-hours lifestyle.

In north Dublin, there are GPs who have not had that requirement. It must be noted there are GPs who do provide out-of-hours service in north Dublin. In the main, most GPs relied on a service so they did not have to be personally available. It is a large change to get these GPs to move to voluntarily providing an out-of-hours service as well as working extensive in-hours. Obviously it will take time to arrive at that point, and, therefore, there will be hiccups.

Deputy Twomey must acknowledge the significant change through the involvement of the Irish Medical Organisation at the highest level. It is playing a significant role in facilitating the discussions. Last week the Irish Medical Organisation was happy to issue a joint statement with the HSE expressing its confidence that the discussions will be concluded. The essential principles of the service have been agreed. The service will be provided by treatment centres, the call centre will be handled by the HSE and the doctors will be responsible for providing the medical care side of the service. The discussions are now at the final detail of the service level agreement. It is nearing the end of what will be a successful outcome.

Deputy Twomey's point on the practicality of commencing the service in September is valid. The HSE, because of the confidence that this will be successfully concluded, is actively involved in organising the infrastructure that will be required for the service. Therefore, the expected date of commencement in September is a realistic one for those reasons.

The Kilkenny model is considered an ideal one for accident and emergency department and out-of-hours services. A core part of that model has been the tremendous co-operation and working relationship between the GPs and the hospital consultants. This is critical to resolving the problems with accident and emergency provision in other areas. The private sector providing community diagnostics is one element of the resolution in this area. The other core element would be the extension of the working day to enhance capacity in the acute hospitals. The building up of community hospitals for provisional services, using what the Deputy referred to as the PACS machine, was also raised.

Are the days of having one's own GP gone? One Deputy pointed out that people are now living longer and referred to coronary artery bypass grafting. For example, surgical intervention has improved the outcomes in heart disease by only a small percentage. Prevention through primary care plays a significant role in combatting heart disease. Professor Starfield at Johns Hopkins University has produced evidence that those health care systems with the lowest morbidity are those where primary care has been built up and enhanced.

When people consider the USA, they often point to what they see on "ER" and the acute hospital sector. However, the USA morbidity rating is not very good when compared with other countries because it has not built up its primary care health system. It has built up a fantastic acute sector and has the highest percentage of GDP spend on its health service. However, the overall health of the population is not as good as that in many other countries. Therefore, primary and community care, which is where people want to be examined, particularly with concerns over hospital acquired infections, is the future. The chief executive officer of the HSE is focusing resources in the medium to long term on this issue.

Deputy Twomey

Can I get access to the documents of the tendering process and evaluation for my research?

Chairman

I thank the witnesses for a good presentation.

The joint committee adjourned at 11.05 a.m. until 9.30 a.m. on Thursday, 25 May 2006.