I welcome to the meeting Dr. Mark Walsh, Mr. Fionan Ó Cuinneagain, Dr. Margaret O'Riordan, Dr. Ailis Ní Riain and Dr. Mel Bates. I thank them for the document they have already presented to the committee and for assisting us in our work on primary care. We are resuming after lunch and members will join us during the course of the presentation. I ask the witnesses to provide the committee with a brief executive summary of the document, after which we will go to members for questions.
Irish College of General Practitioners.
Dr. Mark Walsh
On behalf of the Irish College of General Practitioners, ICGP, I thank the Chairman for the opportunity to make this submission. The Irish College of General Practitioners is the professional organisation for general medical practice in Ireland. Our primary aim is to serve the patient and the general practitioner by encouraging and fostering the highest standards of general medical care. Our core values are quality, equity, access and service to patients. We support the primary health care strategy and the ICGP continues to work with the Health Service Executive and others towards the full implementation of the primary health care strategy announced in 2001 with the restructuring of services providing integrated care throughout hospital and community settings as a priority.
I want to dwell on the strengths of general practice. The existing key strengths of practice provide the foundation for successful reform and must be preserved. Irish GPs undertake in excess of 16 million consultations annually with more than 90% of care being delivered exclusively in a primary care setting. Patients have a real choice in selecting their personal physician for ongoing care. Practices compete for the privilege of caring for patients and their families. Patients enjoy a same-day service as there are no waiting lists in general practice. Ownership and control is vested in the practice partners who have a real interest in maintaining a quality service and making decisions to adapt services to meet patient needs.
The ICGP has identified four critical areas which would facilitate a development of general practice. These are manpower, reallocation of resources, infrastructural development and a new contract for GP services. With regard to manpower, there is an urgent need to increase training opportunities for younger doctors as a greater number of GPs are required owing to several factors. We estimate that approximately 650 GPs are due to retire over the next ten years. Changing gender balance and lifestyle choices for GPs have led to a change in work patterns. There is an increasing and ageing population and more clinical activity is transferring to primary care from the hospital sector.
With regard to investment, it is important to provide enhanced services in primary care and more resources will be necessary. Funding must follow the patient and the reduced demand on secondary care must be accompanied by a transfer of resources to the community. The absence of any movement with regard to the GP contract is a barrier to the development of general practice and it would be nice to see some movement.
General practice can deliver quality care if a number of key points are addressed, including the GP manpower deficit. We need to train more doctors to the high skill level required to meet people's needs. A new contract for services is required, reflecting the changing demands of general practice. Investment in primary care infrastructure and personnel must follow the patient and the implementation of the primary health care strategy in full would be useful.
GPs are highly regarded and valued by their patients. We have a central role in health sector reform. We have worked and will continue to work to improve the quality and standards for general practice for the benefit of our patients. This can best be achieved in partnership with our patients, public interest groups, policy makers and parliamentarians.
I thank Dr. Walsh who stuck to the three-minute time limit.
I will allow my colleagues ask questions first.
I thank the delegates for appearing before the committee and for the documentation they already sent us. Our prime brief in this series of meetings is the development of primary care teams throughout the country. Against this background, one issue I will examine is how to improve the level and quality of care while at the same time having cost savings.
It appears that many general practitioners are frustrated with regard to having direct access to investigative services. They must refer patients to a consultant to get direct access to X-ray and MRI services. A big problem in the north east is the lack of tertiary referral services of any description. The issue arises of GPs being unable to refer patients directly to the specialist units in Dublin. A GP is obliged to send a patient with, for example, a broken jaw to a local hospital. This hospital could lie in the opposite direction to St. James's Hospital but the GP does not have emergency direct access to the latter's services. I wonder whether the college has ever raised the issue with hospitals or the HSE in order to improve the relationship between GPs and hospitals. It is a desperate imposition on patients to send them from Monaghan to Cavan when one knows they will end up in Dublin and it is unfair to make them remain overnight in a casualty department or a ward if they are obviously candidates for Beaumont Hospital or St. James's Hospital. Streamlining the service from a GP perspective would be of tremendous benefit to patients.
I concur that manpower is a serious problem in that the age profile of GPs has increased considerably. We will clearly face serious problems down the road if we do not address this issue. I am interested in hearing what the college would like to see in the new GP contract.
The GP should be seen as the leader of primary care teams. The sophisticated health professionals working as a team in various specialties should report directly to the GP about his or her own patients rather than it being a case of some of them reporting to public health officers based 40 miles away and the GP being unaware of the diagnoses they make.
In regard to generic prescribing, the Irish Pharmacy Union suggested to us this morning that we should follow the example of ten other EU member states by introducing the right for pharmacists to dispense generic medicines. However, it is a question of whether the GP has control over the drugs he or she prescribes. I agree that generic prescribing should be more widespread provided the doctor is satisfied as to the efficacy of the products prescribed. I see merit in the union's argument and am interested in learning the college's view of the matter.
I welcome the delegation and apologise for missing the start of its presentation. I would like to know the level of engagement the college enjoys with the HSE in regard to the issue of teams versus networks and the rolling out of primary care teams. Are the two parties holding ongoing discussions in respect of both the theory and the practice of this policy, as well as the difficulties that arise in various parts of the country? Earlier we were told by IMO representatives that in certain parts of the country difficulties arise with the HSE in terms of setting up new GP practices even though the numbers of patients are sufficient to justify new lists. Is the college concerned about these issues?
The college's submission states that approximately 2,400 full-time equivalent GPs are working in 1,600 practices. How do these numbers fit into the concept of primary care teams as envisaged by the HSE? What is the college's opinion on how these should be configured and who should be on the teams? Yesterday the HSE suggested that a typical primary care team comprises GPs, nurses, home helps, physiotherapists and occupational therapists. How should other groups, such as social workers, dentists, counsellors, chiropodists and dieticians be linked to the primary care teams? This committee is trying to decide what it should recommend in its final report and it is important that we get a sense of how the various professions would interact.
The issue of whether the entire team should operate out of the same building has been raised on several occasions. Is it more appropriate in certain circumstances to work from different buildings or GP practices?
I welcome the delegation from the Irish College of General Practitioners and apologise for being late, but I was doing a radio interview. I have read the submission, however.
The issue of manpower arose in the committee's earlier discussions. What suggestions can the college make on addressing that issue, particularly in respect of partially trained doctors who perhaps already have significant experience in accident and emergency departments and want to become GPs? The idea of making them undergo a four-year training course is a non-runner in my opinion. Has the college any definitive proposals for fast-tracking those who are partially trained so they can be fully trained without having to revisit areas in which they already have experience?
What is the college's view on involving GPs in screening, annual age appropriate check-ups and prevention, all of which are part of the same package? I am aware that Dr. Bates has had an interest in chronic illness programmes for diabetes. I would think general practice has a major role to play in respect of that and other chronic illness programmes in conjunction with practice nurses and, possibly, pharmacies.
Deputy O'Hanlon referred to the issue of generic prescribing, which is Fine Gael policy. However, I am concerned that a patient on chronic medication for an ailment such as blood pressure will become totally confused if his or her prescription is changed every three months in order to find the cheapest medication. I would also like to hear the college's views on a national formulary. I agree with Deputy O'Hanlon that the prescriber rather than the dispenser should be the final arbiter.
What is the college's opinion on specialties such as pharmacy, dentistry and social work forming part of teams? Deputy O'Sullivan referred to buildings. I do not believe it is a case of buildings or services but of buildings housing services. What is the best solution in an ideal world?
Access to diagnostics in the community is a major issue for GPs. I look across the table and see four highly experienced GPs who are more than able to diagnose if they have access to diagnostics. Patients might never have to go to hospital if they can be diagnosed and treated in the community. This is clearly the cheapest option, as well as the most convenient for patients.
I am asking everybody who appears before the committee on this matter the same nasty little question. What is the college's single biggest priority for the future of primary care?
I welcome the delegation and thank it for its presentation. We all identify with the problems of manpower shortages and workloads. However, perhaps it is necessary to work smarter rather than longer. Primary care teams could provide opportunities in this regard. Pharmacists could play a role in chronic disease management in order to relieve pressure on the system. We are all aware of the hours which GPs work and I do not advocate that they work any longer because the day when GPs were on-call 24 hours per day, 365 days per years is gone. Some people visiting the GP may not necessarily need to be there. They are clogging an already overloaded system. We have significant difficulties in our area because GP lists are closed and no new patients are being taken in. Where will these people go? With all the talk and discussion on primary care teams, as Deputy O'Sullivan referred to, what has been the level of engagement of GPs? Apart from the HSE, have GPs been engaging with any other stakeholders, such as pharmacists?
I have a final comment on generic prescribing. We are now experiencing much more stringent economic circumstances and people are looking for value for money. When dealing with a chronic illness and the need for specific medication, there is no difficulty, but I am sure there are areas which could be looked at where it is safe and appropriate to do so. It would have to be conditioned by that. What is the view of the delegation on generic prescribing?
On a point of elaboration on the question from Deputy O'Sullivan about the pharmacists and dentists, they expressed the strong view today that they saw themselves not so much as part of the team but as of part of the network. Where does the delegation see them most appropriately located?
Dr. Mark Walsh
I will start with Deputy O'Hanlon's questions, specifically dealing with how to improve the level of quality of care. That comes with the training we advocate for general practitioners. There is also ongoing education, so people keep up to date. GPs have a good record in this respect.
My question was not so much aimed at the GP level but rather what Deputy Reilly referred to, namely, the links with hospitals where the patients are being pushed around and not getting direct access from the good GPs, who are making a correct diagnosis. They would not have direct access to the appropriate hospital or diagnostics. I am interested in that area.
Dr. Mark Walsh
As a college we have for a long time advocated increased access to diagnostic services and resources. Unfortunately, to date they have been slow to arrive. Where they have been implemented, there is robust evidence that they are effective and more cost-efficient. We are prepared to work with anybody to facilitate that.
Does the delegation wish to address other questions?
Dr. Fionan Ó Cuinneagain
To elaborate on that point, there is a menu of developments that can improve. One example would be structured medical admissions arrangements between GPs and a hospital. That would be important. The diagnostics referred to by Dr. Walsh are singularly absent in the community in so far as general practice is concerned, other than those available through the hospital network. There must be investment in the development of diagnostic facilities in the community rather than the hospital.
Clearly there are other developments outside of primary care that reflect on the issues raised. We welcome the primary care strategy from the outset. We differ slightly with the primary care strategy in how we see the primary care team. It should be developed in an incremental way, starting with the GP, the practice and the community nurse and perhaps the community pharmacy. Everything else builds on that, as the Chairman referred to, more as a network than part of the core team. One of the difficulties is that it is hard to define what is going on around the country in terms of a team versus a network. There are many networks being developed but not necessarily many teams.
Are there any other issues to be addressed?
Dr. Margaret O’Riordan
The college has always supported generic prescribing, which has been there for a good number of years. The focus to date has been in terms of medical card patients only and the consideration of generic prescribing for that group. There is great potential to look at generic prescribing right across the board in the long-term illness scheme and maybe we should be focusing on that.
I agree with Deputy Reilly in that we cannot be chopping and changing somebody on chronic medication every three months because a new generic version has emerged. GPs look at prescribing generically for antibiotics, analgesics and the common things we prescribe on a daily basis.
How does the delegation feel about what happens in ten other European Union countries, where the pharmacist has the right to dispense a generic product?
Dr. Margaret O’Riordan
We should put the patient first. In a quality focus that is no different, so somebody must retain the control over that. The patient has a right to go to several pharmacies. They could go to one pharmacy this week, another next week and if the pharmacist has the right to keep changing the medication, it would not lead to appropriate quality of care if there is to be a patient focus. The GP should retain control over the prescribing.
Are there any other issues?
Dr. Mel Bates
Deputy Reilly mentioned chronic illness care, particularly diabetes. We are keen to promote a shared care approach on this issue. Currently the model is hospital-based and the GP is involved peripherally at times, depending on his or her enthusiasm. I would like to see some sort of structure developed which would support that. With diabetes, the numbers are staggering and increasing all the time. We know hospitals are bursting at the seams with these clinics, which go on until all hours. At some stage we will have to organise a structure and I hope our hospital colleagues will do the same.
Dr. Mark Walsh
The college has published, in collaboration with the HSE and the Irish Endocrine Society, a practical guide to the integrated care of diabetes. This is a template for the management of all chronic illness in collaboration with our hospital colleagues. For this to happen, more resources must be diverted from the hospital setting to general practice, and a new contract might encourage GPs to get involved in the management of chronic illness, the cost of which is one of the major nubs of the health care issue.
Are there any supplementary questions?
I just want answers to the questions I asked. They dealt with manpower and the pharmacy as part of the team. The witnesses have partially answered that. Do GPs have a problem with the pharmacy being in the same building as a GP? The delegation has covered access to diagnostics. There was a comment about buildings; it is not only about buildings as services are also relevant. What are the thoughts of the delegation on manpower or how to fast-track partially trained doctors on to GP level without compromising quality? Nobody wants to see that happen. What of the greater use of practice nurses with regard to screening and chronic illness programmes?
Perhaps I did not put my question very well. The HSE's vision seems to be about having one building with a few GPs, a physio and a couple of nurses and others. I understand from the delegation's response that its vision is of a smaller team built around one GP practice. I want to get a sense of whether GPs have engaged with the HSE on that matter and if the larger concept of the HSE might be appropriate in certain locations and the other vision in different locations. I am trying to get a sense of where the representatives are in terms of buying into the HSE's concept and whether there is some flexibility. Obviously it will not work if GPs do not buy into it.
To elaborate on Deputy Reilly's point about GPs in training, are we aware that there are sufficient numbers of GPs in training to meet the demand?
Dr. Mark Walsh
There are probably not enough GPs in training. We have pleaded for an increase in the allocation for training of GPs.
Is the problem that people are not opting for general practice or that there are not enough training opportunities available?
Dr. Fionan Ó Cuinneagain
It is the latter. For example, for this year's intake — we are still assuming there will be 120 places available — approximately 350 eligible applications have been received.
Do we know what the optimum number of GPs is? How many would be required on an annual basis?
Dr. Fionan Ó Cuinneagain
We have put out a figure of 150 per annum and that was a target for last year. It needs more fundamental research. There is a need for a review of primary care manpower to clearly identify the relevant or appropriate work for all of the professionals involved. The roles of the practice nurse and the pharmacist were mentioned. It could well be that some work could be delegated, particularly in chronic care management, for example, to the practice nurse, which would then open up time for general practitioners. We need to sit down with all the parties and consider the question fundamentally from that point of view.
In answer to Deputy Reilly's question about fast-tracking general practice training, we have made a proposal to the HSE on what we call phase 2 training. This recognises any prior hospital training. If people had the appropriate level of hospital training, which is two years, under their belt they could then commence the two-year GP training directly. There would be some catching up because of the need to introduce them to general practice. It has not been possible to fund that. We are in discussions with the HSE about where we can go in terms of expanding the numbers. The HSE has acknowledged there is a need for expansion but it is not forthcoming, or cannot be forthcoming, with the funding.
What about Deputy O'Sullivan's point on engagement with the HSE and the HSE's vision?
Dr. Mark Walsh
We have engaged with the HSE. Much of the development of primary care is happening at local level between the local health offices and general practices, and there is room for flexibility. A large building with several GPs and several units in it may suit large urban areas, but there are rural areas where that would not be feasible or possible. Flexibility is the key; it is the core team rather than the actual building. We have to meet the demands of the various communities in developing our teams.
Dr. Ó Cuinneagain stated that there were 350 applications. Is he saying there are 350 people who would be interested in pursuing this if there were places available?
Dr. Margaret O’Riordan
Yes.
Of that 350, how many are coming in following the leaving certificate?
A Member
They are qualified doctors.
The witnesses are talking about qualified doctors. I thought they were talking about 350 places.
Dr. Margaret O’Riordan
No.
Can I clarify something? I have discussed this with the college before and it is something that is close to my heart. I know Dr. Ó Cuinneagain has just said that 150 places is what they are aiming for, but in view of what we heard earlier about demographics — that we have a tranche of GPs retiring and that the new GP is not the whole-time equivalent of what used to be a GP because of the hours worked — we are currently facing a major manpower crisis. Given the fact that even as we speak we have only one GP per 2,500 patients north of the Liffey, as opposed to one per 1,200 or 1,600 nationally — I am not sure which — we need to be training 200 to 300 GPs per year in order to catch up. Without putting words in Dr. Ó Cuinneagain's mouth, is that not so?
Dr. Fionan Ó Cuinneagain
That is so.
I am talking about a defined period of perhaps five years to catch up.
Dr. Margaret O’Riordan
Yes.
Would 150 or 200 be enough thereafter? We are talking about chronic illness programmes and more work going in the way of general practice, which is where it should go, as it is the lowest level of complexity and the cheapest treatment.
That has been very helpful and has clarified the point. Are there any remaining points or questions that have not been dealt with?
Dr. Mel Bates
I have one point with regard to Deputy O'Sullivan's question about the college supporting GPs in solo practice, which I got the impression we had left unanswered. Obviously we do support them — we do not exclude that — but there is a general move towards connecting up, much more so than previously. We always stress that what the patient wants locally is what matters, and in certain locations around the country a single-handed GP is the best option. However, most people are moving into group practice.
I think everyone is happy. I thank the witnesses for the time and information they have given us. We may need to engage by way of correspondence as we move towards completing our report. I thank the witnesses for their help.