Léim ar aghaidh chuig an bpríomhábhar

Seanad Éireann díospóireacht -
Wednesday, 9 Jul 2014

Vol. 233 No. 2

Health (General Practitioner Service) Bill 2014: Committee Stage

I welcome the Minister of State, Deputy White, to the House.

Sections 1 to 5, inclusive, agreed to.

As amendments Nos. 1 to 7, inclusive, amendment No. 9 and amendment No. 10 are related, they may be discussed together by agreement.

What is the ruling on amendment No. 8?

It is out of order.

I appreciate that I am putting the Leas-Chathaoirleach on the spot. I received correspondence this morning to the effect that amendment No. 8 had been inexplicably ruled out of order.

The reason given is that it is a potential charge on the Exchequer.

I must say I do not accept the suggestion that it would impose an extra financial burden on the Exchequer.

I will allow the Senator to make that point when we reach the amendment in question. The best thing to do at this stage is to concentrate on amendment No. 1 and the related amendments.

I move amendment No. 1:

In page 7, between lines 10 and 11, to insert the following:

6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) Notwithstanding any other part of this section, the agreement, referred to in subsection (1) shall not:

(a) include any provision to restrict the criticism of the Health Service Executive, or the Department of Health;

(b) impose an obligation upon any general practitioner to limit criticism of the Health Service Executive, or the Department of Health;

(c) require any general practitioner to notify the Health Service Executive, or the Department of Health in advance of making a public statement;

(d) require any general practitioner to receive prior approval from the Health Service Executive, or the Department of Health, for any public statement they wish to make;

(e) require any general practitioner to dilute their natural rights to freedom of expression implicit in article 40.3.1, of Bunreacht na hÉireann and explicit in article 10.1 in the European Convention on Human Rights.".

Cuirim fáilte roimh an Aire Stáit. It is good to have an opportunity today to discuss a part of our health system that does not get the attention, credit, support or resourcing it deserves. I believe it faces a number of threats, some of which are being added to by the potential actions of the Government in this regard. General practice in Ireland, which is sometimes called primary health care or family practice, is the least dysfunctional part of our therapeutic health system.

The three great sins of our very dysfunctional hospital system are that it is inefficient, of mediocre quality and tremendously unequal. General practice addresses most of these through varying degrees of success and is certainly more successful than the hospital system.

In the first instance, unlike our hospital system where much of the care is delivered by trainees, patients who see a general practitioner, GP, will see a fully trained specialist in the speciality of general practice. They will see an appropriately experienced competent, well-trained doctor who will give them the care which they deserve. That is one-nil to general practice versus the hospital service. A group of quasi-independently operating GPs provide a very low overhead and low administrative-burdened service. Much of the money spent on the service is actually spent on providing care rather than administering care, unlike our hospital system.

Third, and spectacularly, is the equality issue. Patients who go to a general practice will pay either out of their own pocket or have the service paid for by the Exchequer through the medical card scheme. The point is that they will all have been seen by the same doctor, in the same surgery and waited the same time. Essentially, they will all have had the same access to care. This is a system that works relatively well. We mess with it at our peril. Instead, we should be fostering and encouraging our GPs.

I hope the Minister, Deputy Reilly, is given the opportunity in the years to come to continue with the reforms he has instituted in the health service. We have a need to foster a culture in which we remove much of the inappropriate care which takes place in hospitals and put it into the primary care setting. This will not happen accidentally but only when the appropriate development and investment in the primary care service is made. It will only happen by encouraging medical practitioners to go into primary care, to stay in it and not go part-time or leave the country. I have had extensive consultations, like the Minister, with many representatives of the general practice organisations who are feeling very concerned about the future of their specialty. They are concerned that some of the administrative reforms which will be introduced will make it a much less attractive speciality. They see a new way of defining a group of their patients with the free care for children under six which will impose a whole series of administrative burdens on them. There will be a statutory obligation on them to perform extra evaluations which they have not had to perform before. Neither are these well validated or based on a good scientific, evidence-based medicine approach. There is also a subtle cultural inference that GPs are becoming more direct employees of the public service, losing some degree of their critical independence and their power to make their own decisions.

There is an ability often used appropriately to very good effect by all front-line public service health professionals to identify problems in services and advocate on behalf of their patients. Another area of concern to GPs is that this might be in danger of being subsumed into a corporatist mentality. Like a form of neo-Stalinism, it suggests that if one does not actually agree with what the corporation or the system is doing, then one is being disloyal to the system. The primary loyalty of any health care provider should be to their patient, not to the system. We all understand we work, operate and practice not in a vacuum but in a context in which there are communal as well as individual obligations. However, if we begin to impose any kind of a gagging order on GPs in determining whether they can or cannot be signed into the scheme and, accordingly, be a participant, then we are giving the State an inappropriate and awesome level of power.

Amendment No. 1 prohibits this from happening. I understand this was included in the previous agreement and there was ample reassurance that there would be no question of a gagging order. Accordingly, I cannot see any reason there would any objection to this amendment.

This new contract will extend the current General Medical Services scheme to a new group of patients, namely, those under the age of six, regardless of health or natural circumstances. I am supportive of this overall. However, it imposes an extra burden of clinical responsibilities in routine evaluations and other interventions on GPs which do not occur elsewhere in the existing GMS agreement. As such, I am not sure as to why there should be this two-tier approach. Why should one group of patients be treated differently from others? GPs will find this obligation onerous. Until there are adequate levels of resources in general practice, more GPs, better doctor-patient ratios and appropriate levels of administrative support to enable GPs to have their time freed up exclusively for clinical care, then they do not want to waste their time. They have a sense this agreement or contract will force them to spend a big chunk of their time doing routine assessments on people who are healthy at the expense of other people who are ill while, in the process, potentially increasing waiting lists, etc. In addition, we are a little troubled that this agreement is term-time limited as opposed to the permanency of a GMS contract. GPs are thinking this is the thin end of the wedge to introduce this kind of contract to the broader GMS scheme and, as such, they are very concerned about it.

Setting minimum requirements for practice premises is unnecessarily intrusive. Either a GP has an adequate practice premises or they do not. It struck many of the potential participants in this contract as being yet another stick with which they could be beaten.

My GP colleagues are troubled by an apparent opening of a little chink in the armour of doctor-patient confidentiality. Those who sign up to this contract are becoming more deeply embedded within the system. It is not clear, however, that there is an absolute respect for doctor-patient confidentiality as a result. As I always say to patients, they must know the only person I am giving advice to or caring about is them. As a policy advocate, I may have positions that would involve resource allocation issues which could limit access of certain people to some care because others cannot get more important care. A patient sitting across from a doctor’s desk needs to know the only person the doctor is thinking about is them and the only person who will have access to their records is the doctor or another professional with whom the doctor believes it is in their interest to share it. There is a sloppiness in the wording of the agreement which leads us to believe there could be a vulnerability on the question of confidentiality, with which we are not happy.

My GP colleagues also feel that it needs to be clear that if one has qualified or does not have a disciplinary action against one or any other impediment, then there should not be any other administrative impediment for one to sign up to this contract. Historically, general practice has not been a big offender in this regard. However, in this country extraneous factors often go into someone’s ability to apply for a publicly funded contract. It needs to be spelled out that no spurious impediment could be advanced in the way of a GP with a clean record and who is appropriately qualified and experienced.

Am I now at the end of this section of the amendments? Are we breaking and then addressing the last two amendments?

If Senator Crown wishes to hear what the Minister of State has to say, he can always come back in. If there are any issues, the Senator can come back in as many times as he wants.

This is a busy few days in the lives of the Minister of State and all the other Ministers, and I am not anxious to delay the proceedings any further. I would be delighted to hear the Minister of State's replies to my amendments.

Before the Minister of State comes in, Senators Colm Burke and Gilroy wish to make a comment.

I welcome the Minister of State to the House and thank him for the work that he has done. I note there will be some changes but, in fairness, all of the Ministers at the Department of Health, Deputies Reilly, White and Kathleen Lynch, have been extremely innovative and hardworking in dealing with the Department over the past few years. There is a lot of work done, but a lot of work still to be done on the required reform.

On the amendments put forward by Senator Crown, it is important that we would have a debate on the important issues he has raised. I attended a GP meeting in Cork. There were over 350 GPs at it and they raised all of the issues that Senator Crown raised. It was of concern to them that a draft contract was put up online and there was an impression given that it was written in stone. I am glad that such a message has changed, that there is ongoing consultation and discussion with the IMO. In fact, I spoke with the IMO as recently as this afternoon and it confirmed that those discussions are ongoing, which is welcome.

On Senator Crown's amendment on not having any restrictive clause on contracts, I support what he is saying but do not think it is necessary to have it in legislation. If one tried to put that into a contract, any court would hold that where there is a valid public concern in relation to health care, general practitioners and medical practitioners generally are entitled to bring that to the attention of the general public and one cannot restrict people in any way from making public comment. I know of staff who work with the HSE and while they may have got warnings from HSE administrators that one cannot make public comment on issues, where there is an issue where it is important that the general public is aware of genuine health concerns then they are entitled to bring it to the attention of the general public.

It is also important that medical practitioners are entitled to debate and make available information to the public as regards why a particular service is having difficulties and why they are having difficulties in delivering a service, either through lack of resources or through lack of the necessary support staff. It is important that there is no restriction. While I would agree with what Senator Crown is saying, it is not necessary to put it into legislation.

Senator Crown referred to general practitioners. General practitioners have provided a superb service in this country over a long number of years. We need to acknowledge they make a considerable commitment and are dedicated, and provide a high level of care to their patients. Every GP I have ever dealt with has gone away beyond the call of duty in the level of care he or she provides to his or her patients. It is important, therefore, that in the introduction of any new scheme to expand the number of medical cards or GP-only cards there is full consultation with that group of medical personnel. I am delighted to see that the IMO, as a representative body of doctors, is engaged with the Department at this stage. The concerns general practitioners raise are listened to by the Department and the HSE.

One of the issues I want to touch on which is not covered by these amendments is an issue on which I published a Bill, namely, the requirement of all medical practitioners in this country to have insurance. I am not clear whether or not we are writing that into the contract that is now being provided. While one cannot drive a car on the road without having insurance and I cannot practice as a legal practitioner without having insurance, there is still no legal requirement on medical practitioners to have insurance. I suppose it is not really a big issue in the case of general practitioners as such.

Where it is a real issue is in relation to those who are providing cosmetic surgery, particularly where staff are coming in from abroad to provide it. We still do not have such insurance legislation in place. The Bill I published seems to have been parked and we do not seem to have made any progress on that over the past two years. The Minister, Deputy Reilly, introduced his own Private Members' Bill in 2009 and here we are five years later and we still do not have that legislation in place. It is something that should be given priority. A requirement to have insurance is certainly something that should be put in place as a condition in contracts for GPs. I am not too sure whether or not it is included in the existing contracts but it certainly should be introduced.

The other issue I wanted to raise with the Minister of State relates to services being offered by GPs. I understand there is a difficulty where some practices began to offer scanning services. I discussed with the MPS and other insurers who provide insurance for GPs whether this service is covered by normal general practice insurance. It is also something that needs to be looked as there is a growing number of practices offering scanning service. It is a welcome development, but it is also important that there is adequate insurance cover for them and that they fully understand that their insurance policies provide such insurance.

I welcome the decision by the Government to provide free GP care for those under six years of age. While there has been much criticism of it, there are many young families which are falling into the trap where they find it difficult to get private health cover and do not qualify for medical cards. This is one development which is welcome, especially to give support to those who have young children so that they have access to medical care when they require it. I certainly hope that the consultations and discussions with the IMO come to a satisfactory conclusion and that this scheme can be started at the earliest possible date. I thank the Minister of State for bringing forward this legislation.

Senator Crown gives a good description of the services provided by the GPs and there is not a single person on this or any side of the House who does not agree with virtually everything he says on this. I would be inclined to go a little further and say that the services offered by GPs are pivotal because they are the gatekeepers of the services.

Senator Colm Burke referred to a meeting of 350 GPs which took place in Cork earlier in the year. I was at that meeting. I went further, to another meeting in Tralee where there were another 85 GPs present and I listened carefully to their concerns. Senator Crown seems to outline clearly and succinctly the concerns expressed by the GPs with regard to the proposed new contract. However, we cannot support Senator Crown because what is in the legislation and what is in the contract are two different things, and we are talking about the legislation here today.

Amendments Nos. 1 to 7, inclusive, as proposed by Senator Crown, would have the effect of binding the Minister's ability to negotiation the new contract and we must remember that the Minister is the upholder of the public interest here as well. Either as a legislator here in the House or in the other part of my life where I spent ten years as a trade union negotiator in the health service, I have never come across a proposal to so bind a Minister. I have never seen either the necessity or the desirability of including the amendments that Senator Crown proposes in legislation.

While I would share most of his concerns with regard to the negotiation of a new contract, both separate issues, restraining the Minister in his negotiations with a third party with regard to their contract is not what we would like.

I welcome the Minister of State, Deputy Alex White. I have different views on the Bill. While I am supportive of almost everything Senator John Crown has said. However, I am not sure I support amendment No. 3 which states: "The agreement, referred to in subsection (1) shall not require any general practitioner to perform annual, or otherwise periodic assessments of patients who are healthy." I understand that in China - I am not sure if this is still the case - the doctor got paid if one was well. His job was to keep one healthy, and he did not get paid if one got ill. That is an excellent idea. I would hate to think if we accepted Senator John Crown's amendment that it might restrict the opportunity to do that at some point in the future. However, everything else he said makes sense.

I grew up in the marketplace and I am used to the customer deciding whether to go here or there or whether to buy this or that. Currently I have that freedom. Is there any danger that freedom will be taken away? As a patient living in a locality, I have been with the same GP service for more than 40 years but I have a choice in the practice as to which doctor to go to. In that area I have a choice of half a dozen GPs to whom I can go. I am concerned that 98% of GPs said they would not sign the particular contract. I understand what Senator John Gilroy said that this is not the contract. We are not talking about the contract here. The GPs claim that no negotiations have taken place in regard to the contract. Will the Minister of State please put my mind at rests that is not the position? I believe my contract with my doctor is with that doctor, with that GP, not with the HSE. It appears to me as though Big Brother is coming in.

GPs say they would have to agree to do the work as dictated by the HSE and other government bodies. These could inspect the GP, interview his or her staff and take his or her records as they wished. I do not see that in the Bill and ask the Minister of State to put my mind at rest. I understand Senator John Crown is concerned that the freedom for the GPs to give the advice and medical service will be interfered with by the State. I do not think any of us want that interference and I doubt if the Minister of State wants it. Certainly, I do not believe patients want it, they want to be able to deal exactly as Senator John Crown said, that is with their GP on a confidential basis. All of the points he has made make a great deal of sense and I ask the Minister of State to put my mind at rest in that regard.

I welcome the Minister of State. We have had an Adjournment debate on this issue. Like others, I have attended a meeting in Galway of approximately 250 GPs where I learned that it is the one part of the health service that is working well. Some 98% of GPs reported that their patients did not need to go to hospital and that they were able to deal with them and that they were being resourced by a very small proportion of the health budget. The figure escapes me but I think it is less than 5%. Perhaps the Minister of State would clarify that. This is a patient-doctor relationship that is working well. I would not like to do anything to dismantle that service. Given that 98% of GPs are not willing to work with the Minister on free GP care-----

That is not true.

That is just not true.

I accept that but I know that there is a large number-----

The Minister of State can respond to those questions.

I appreciate this is an opportunity for an interchange where we will get the facts. Given that the majority of GPs are not willing to sign this contract-----

We do not know that.

-----I am concerned for the patients because I do not want a free GP service for under six year olds that is only a service in name. The information available to me from the UK is that one can wait seven days for a seven-minute appointment. If I have a sick child under the age of six years - I have had occasion to be that mother - I do not want to wait even for one minute once I know the child is ill. In those circumstances, I have to find a doctor straight away, therefore, I will have to pay unless that person is on my doorstep or local. We have had situations in Galway, with which I am sure the Minister of State is familiar as they have been well documented, whereby we could not get GPs to take up the lists in remote areas. We have situations where many of our young doctors are leaving the country, so why are we seeking to reduce the service which is effectively what will happen?

I want a relationship with a caring GP, not with a bureaucrat. For that reason I support many of Senator John Crown's well-crafted amendments. Perhaps I can speak to one or two specifically. The amendment with which I have great difficulty is the one where GPs would be gagged and would have to sign a confidentiality clause. We want to ensure the doctor is not hamstrung and is not whipped by bureaucracy as there could be occasions when that would be dangerous to patient care. We must remember that doctors have to lobby. If they are gagged or have to sign a confidentiality clause that could be so restrictive that at the end of the line the patient would lose out. An important issue for me is that they would always act in the interest of the patient and would not be restricted in doing that.

The issue raised in amendment No. 3, in the name of Senator Crown, was raised during the meetings. In theory, I support universal health care. I voted and lobbied for this but as a country I do not think we can afford it right now. I want to see the people in need getting the service, that the service would follow the need, and that the money would follow the patient in need. I would like the time and resources of the GP spent on the person who is unwell. By making the service universal we will clog up waiting rooms in a way that could come against the people who suddenly have a child with a very high temperature, spots or whatever, or meningitis with no possibility of getting an appointment quickly.

Speaking to amendment No. 6, it is critically important that medical records are limited to the medics and would be released only with the consent of the patient. We do not want information used in a way that is not intended other than for the well-being of the patient. I believe that should be restricted to the important GP-patient relationship.

Amendment No. 10, which we are also discussing-----

No, we are not. It is amendments Nos. 1 to 7.

I will hold on that amendment.

I look forward to the Minister of State's replies on where the negotiations are at in terms of the percentage of GPs who are not willing to sign the contract, given that there has been a number of moves since I raised the matter on the Adjournment. Based on the Minister of State's knowledge of the take-up of GPs, how reliable will the service be? For example, I am based in Galway. Will I have to travel ten miles to get a GP who is willing to sign up to this contract or will have to travel 20 or 30 miles if I am in rural Galway? Those are critical issues. What is the point in having a service in name if it is not a service that will deliver when one has a sick child under six years of age?

I welcome the Minister of State.

I agree with virtually everything Senators Crown, Gilroy and Colm Burke have said. The general practitioner service is the part of the health service that works. In a situation in which well over 90% - I am sure the Minister of State can correct me on the number - of people who attend accident and emergency departments are never admitted to hospital, does this not illustrate the scope for developing the GP service? I would like to see such a service provided in the evenings and at weekends because, after all, people also get sick at those times. I also would like to see group practice GPs, in which perhaps three or four people got together. If one had been involved in sports in college, he or she could specialise in that, while another may have an interest in paediatrics and so on. There is scope in this regard because once one gets inside the door of a hospital, whether into the accident and emergency department or certainly if one gets upstairs to the beds, one's costs will be far higher than the €55 the Minister of State mentioned on Second Stage as being the cost of a GP visit.

Senator Crown has extolled the virtues of the doctor being fully trained. He or she has low overheads and it is not a two-tier system. Moreover, the GP service does not have the edifice complex with which the Minister, Deputy Reilly, and the Minister of State must deal in the Irish health service, whereby we keep on closing hospitals and opening new ones. It seems to be never-ending and the arguments always are about buildings and edifices, not about patients. It is important that the general practitioner service be kept onside. I do not know whether there have been developments in respect of the National Association of General Practitioners. There appear to be some differences of opinion between that association and the Irish Medical Organisation, IMO, which appears to be the negotiating body. However, as Senator Healy Eames has noted, society as a whole, including all Members, would not like to have any GPs who are unhappy in this regard. This is an important part of the health service and Members wish to ensure the Government is negotiating with people who represent the entire sector.

As for the GPs, if I take the 410,000 children who are aged between zero and six, according to the Start Strong report, the Minister of State's estimate was that approximately 40% of those children already have cards. The Minister of State may have more up-to-date figures in this regard. Consequently, this measure pertains to the remaining 60% of that 410,000 population. As I perceive it, this will change the relationship between 250,000 patients or customers of GPs and they are entitled to be concerned. They appear to be quite happy, and on Second Stage I mentioned the income distribution statistics to the Minister of State. I appreciate that in a policy sense, the Minister of State wishes to have them included but under no measure of poverty do the aforementioned 250,000 people count. They are not in DEIS schools, they are not in consistent poverty and they do not qualify under the survey on income and living conditions, SILC, study. Nevertheless, it has been decided politically that this relatively well-off section of the population of 250,000 people are to have their relationship with their GPs changed. While this is a relationship I consider to be working, it is getting the intervention of the bureaucracy, the kind about which Senator Crown has expressed concern. In a health service that still employs approximately twice as many bureaucrats as it does doctors and dentists, I share that concern. The system is working well and there is no need to have layers of bureaucracy involved. If one wishes to help people on low incomes, that should be done directly through the medical card system by extending eligibility as the circumstances of the country permit.

However, I refer to the suggestion that these additional 250,000 people, whose parents currently pay the €55, can be catered for with €37 million, which is the figure the Minister of State mentioned on Second Stage. This does not stand up because the last time something like this was done, I believe most ill-advisedly, was when medical cards entitlements were extended to the over-70s. The first budget was €19 million for 39,000 beneficiaries but the outturn, as the Brennan commission report stated, was €55 million for 77,000 beneficiaries. Moreover, it was necessary to introduce a gold card system because some private patients were worth more to the doctors concerned than was on offer from the State by giving them all medical cards. Consequently, on the track record, I worry about the cost. Had I tabled an amendment today, it would have been to propose the capping of this programme at the €37 million figure mentioned by the Minister of State. At present, the General Medical Services system costs €2.8 billion and to extend it by quarter of a million people for €37 million will require some miracle of loaves and fishes. I worry about that aspect.

I also worry about what it is doing to the GPs. I prefer the system in which they themselves provide the premises and the involvement of building sections is avoided. When the arguments about Balbriggan, medical centres and so on arose, my question was to ask why build them at all. I was not interested in whose constituency they were but in why they were necessary when this was a job the GPs had been doing well for decades past. If one wishes to help people with low incomes or if one wishes to extend eligibility to other people, a goal I do not share in this instance, one should not undermine a system that has served us well in the face of massive costs in accident and emergency departments and the unnecessary frequenting of such units. The Minister, Deputy Reilly, has referred in this House to the deskilling of GPs because a hospital culture has been built in which people do not think it is the practice of medicine unless one gets a letter to attend a hospital. People have stated that sometimes GPs are virtually confined to letter-writing, that is, to an employer to state someone is sick when he or she is not or to a consultant when the treatment could take place in the GP surgery. I would like to see that service developed and the freedom to comment, which doctors always have had our society and which is covered by Senator Crown's amendments, retained and enhanced. I worry about turning GPs into civil servants, given the problems we have had in the health service heretofore. Again, however, the Minister of State is most welcome and I value the manner in which this debate is organised, as it allows Members to refer to so many aspects that I hope will be of assistance to the Minister of State in what I definitely hope will be an ongoing role in developing the GP service. I thank the Minister of State in that regard.

On a point of clarification for Senator Healy Eames, she asked a question regarding amendments Nos. 9 and 10. While they are all grouped, she may come back in, even if I am not in the Chair.

I thank all the Senators for their extremely helpful contributions on these amendments and I will address some of the specific matters raised shortly. As agreed by Members, amendments Nos. 1 to 7, inclusive, are being taken together. These proposed amendments seek to insert new sections after section 5, which effectively seek to determine the shape of the GP contract for the provision of services to children aged five and under. With respect, it is not appropriate to include provisions in legislation that would restrict the terms of any agreements which the HSE may enter into with GPs for the provision of services to children aged five and under, as provided for in the proposed section 58C(1) in the Act of 1970.

Members will be aware that the Department of Health and the HSE are currently in discussions with the IMO within the context of the framework agreement I signed on 4 June last. This framework agreement sets out a process of engagement on all aspects of the GMS contract with GPs with due regard to the IMO’s representative role and within the context of legislation underpinning the introduction of GP care free at the point of access. Substantive engagement with the IMO is under way with regard to the draft contract for the provision of services to all children aged five and under. Under the aforementioned framework agreement, the IMO can fully represent its members in respect of discussions around all aspects of this draft contract, including fees, and in respect of the GMS contract. That is the appropriate forum to address the concerns of GPs concerning the draft contract, which was published on 31 January 2014.

I do not propose to accept the amendments proposed by Senator Crown.

Amendment No. 1 is clearly prompted by what has been referred to as a gagging clause in the draft contract. The specific clause in the contract as published, which is clause 28.4.4, was intended to reflect and be protective of the HSE's interests given that the primary statutory obligation to provide general practitioner medical and surgery services will rest with the HSE. It is not in any sense intended to impose unwarranted or inappropriate restrictions on individual GP contractors advocating on behalf of their patients. The clause in question should be viewed in the context of the entire draft document where the intent is to balance the duties, obligations and rights of both parties while at the same time having due regard to the overriding statutory obligations that will rest with the HSE. Nevertheless, in view of the reaction to this clause in particular, the HSE and the Department are willing to discuss the matter further with the IMO. There is no intention on my part or on the part of the Department, the Minister or the HSE to effect the kind of restrictive environment that seems to be suggested in the amendment.

While I do not propose to accept the amendment, I am sympathetic to the thrust of the points the Senator made. It would not be appropriate to restrict criticism, impose obligations to limit criticism in the kind of circumstances he outlined, require a GP to notify or get prior approval from the HSE in advance of saying something or in any way dilute the natural right to freedom of expression implicit in the Constitution. Although I have huge respect for the Members of this and the other House, I do not think it is appropriate or even possible for them to manage the negotiations on this contract. I say that with all the respect that is due to Members. Negotiations on any contract are a matter for the parties involved and that is how matters should proceed. I accept that there are concerns about the aforementioned clause. The Department and the HSE are committed to addressing such concerns and, for my own part, I believe the matter can be resolved to the satisfaction of both parties.

Section 58C deals with the contracts the HSE may enter into with GPs for the provision of GP services to all children aged five years and younger. Subsection (1) provides that the HSE may enter into a contract on such terms and conditions as it considers appropriate, and subsection (2) provides that the contract shall specify the services to be provided by the GP. The proposed amendment No. 2 seeks to ensure the contract shall not include greater specification of services to be provided by the GP than is included in the GMS contract. The draft under-six contract encompasses the strengths of the existing GMS contract while also seeking to address, in so far as is practicable, its weaknesses and limitations. This new draft contract provides a unique opportunity to refocus primary care towards prevention and health promotion, in addition to diagnosis and treatment. It is wholly appropriate that a contract being introduced in 2014 should reflect the requirements of today rather than simply reflecting the terms of a GMS contract introduced 25 years ago. If the amendment were accepted, it appears it would confine the services to be offered under it to those already provided. I do not regard that as appropriate and I am not prepared to accede to such a proposition.

In regard to amendment No. 3, when drafting the contract consideration was given to the document, Healthy Ireland: A Framework for Improved Health and Wellbeing 2013-2025. This is the Government's national framework for action to improve the health and well-being of the population over the coming generation. Based on international evidence, it outlines a new commitment to public health with an emphasis on prevention and stronger health systems. This is related to Senator Quinn's point on China. It addresses risk factors and promotes protective actions at every stage of life, including early childhood. Healthy Ireland has been informed by feedback from an extensive consultation process with Government, the health sector and the wider public and provider society. It reflects international experience and evidence of what determines health and reflects best practice on how to prioritise and invest for long-term sustainable health benefits. A key feature of the draft contract is to refocus primary care towards prevention and health promotion, in addition to diagnosis and treatment. As well as ensuring equitable access for young children to health care, GP care without fees will reduce the financial burden on young families, many of whom face unemployment and negative equity. It also increases the likelihood of conditions in children, such as obesity, being identified and addressed at an earlier stage, and of vaccination rates being maintained. A broad range of evidence from the international scientific literature attests to the value of health checks and health-promoting activities for issues such obesity in early childhood. The detail of the relevant clause of the draft contract, that is, clause 13, will be discussed with the IMO within the terms of the framework agreement referred to.

Perhaps Senator Crown will disagree but to say there should not be annual or periodic assessments is tantamount to saying there should be no assessments. It is problematic, at the minimum, to suggest we should not have health assessments of persons who are healthy. That may be a point of disagreement between us but I think it would be inappropriate to exclude such assessments from the remit of the contract. This is intended to be a contract with GPs but not all the services we are proposing to contract with a GP need to be carried by that individual. This issue turns on the configuration of staffing and resources for general practice. Practice nurses and many other well-trained primary care professionals are capable of carrying out much of this work. If the contract is for the provision by the GP of a service, he or she does not have personally to perform all the individual actions required, whether they involve weighing a child or taking bloods. Many of these tasks can be carried by other trained primary care professionals. However, the contract for delivery of the service is with the GP.

Amendment No. 4 refers to the contract duration. The draft contract proposes a contract duration of five years, with the option of extending it for further periods of five years subject to satisfactory outcome of performance reviews. Performance reviews are a widely recognised feature of contracts for services and for this reason they have been included in the draft contract. To the extent that there is a concern about restrictions in the number of years, that is amenable to negotiation and engagement among the parties to the contract. It is wholly unsuitable to suggest some form of statutory intervention into the matter. It should and will be a matter for discussion with the IMO.

In respect of amendment No. 5, clause 13 of the 1989 contract includes minimal requirements for practice premises. For example, the contract requires a waiting room with a reasonable standard of comfort and hygiene sufficient in size to accommodate the normal demands of the practice for both eligible and private patients with adequate seating.

Second, a surgery sufficient in size for the requirements of normal general practice, with facilities, including electric light, hot and cold running water, an examination couch, and other essential needs of such practice, including a telephone. That is the existing position.

Clause 12 of the new draft contract seeks to build on these requirements to reflect current needs and expectations. However, I again emphasise the comments received as part of the public consultation process and those made today concerning practice premises and the term of the contract have been carefully noted and these issues will be discussed further with the IMO. In regard to the plain intent of amendment No. 5, the Senator is perhaps unintentionally calling for a situation where there would be no minimum requirements set for practice premises. That would be a regression because it would seem to suggest that even the minimum requirements there currently ought to be removed as it has been suggested there should be no restrictions.

In regard to amendment No 6, I emphasise there is no intention to interfere with the doctor-patient relationship and the contract will not provide for any inappropriate sharing of patients' medical information. This was raised in recent months and it will be discussed with the IMO. Any concerns as to what is intended can be addressed in that context. I will return to the matter in a moment, if I may.

In regard to amendment No. 7, section 58C provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and younger. The requirement is that a doctor is registered on the specialist division of the register of medical practitioners and holds a current certificate of registration in respect of the specialty of general practice. This is not new as the Health (Provision of General Practitioner Services) Act 2012 includes the same requirements.

However, the Bill provides that the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six-month period following commencement of the section. This is in recognition of the fact that some older doctors, while fully qualified, may not have registered on the specialist register. The draft contract includes a reference to English language competency but, I would respectfully say, there is no need to go in to this level of detail in the legislation.

The 1989 contract includes procedures concerning complaints, suspension and termination of the contract. These are important features of any contract. However, the draft under-six contract includes a more comprehensive, practical and fair set of processes and procedures, including disputes resolution arrangements. These arrangements will be the subject of further discussion with the IMO.

I wish to respond to some of the points I may not have fully addressed. The House would expect me to say, but I want to emphasise it, that there is no intention in anything we propose to do in this legislation or elsewhere to undermine or still less, to use Senator Healy Eames's phrase, to dismantle our system of primary care and our system of general practice. Why would we do such a thing? Why would we have such an objective? It is absurd. We seek to improve and enhance primary care and the provision of our health service. Everybody in this House wants to achieve the same objective. We may disagree about some of the policy choices but there is no wish, in any sense, to undermine what we do.

There is ample evidence that fees at the point of delivery for general practice constitute a significant barrier to attending one's general practitioner. This is not just my assertion. The evidence is very considerable. People, even relatively well-off people, put off going to see their doctor because of the barrier of fees and I have read studies on this. People like me and most Members of this House, who are not medically trained, are not in a position to make an informed decision as to whether we need to go to see a doctor. I would say with respect to Senator Quinn that sometimes the issue of the market intervention or the fact there is a fee and a commercial relationship enters into that dynamic and I would respectfully submit that it should not. I am not opposed to the market determining distribution of services and resources in different parts of the economy and society but perhaps this area is arguably wholly unsuitable to the question of how one distributes and facilitates the distribution of health care.

The fees have been shown demonstrably to be a barrier to attendance. As people do not go to see their doctor, because they do not wish to pay €50 or €55, we cannot begin to encourage them to come into primary care for the preventative strategies we want to put in place in primary care. Who will go to see his or her doctor about a problem he or she thinks he or she might have in 20 years' time? Who will go to see his or her doctor to say he or she thinks he or she might be a candidate in ten, 20 or 30 years' time for diabetes? Who will pay €50 or €55 for that exercise? It is very unlikely people will do so.

We use the term "free GP care". I was criticised for making the following comment in the media. I said I accept - I think this will please Senator Barrett - that nothing is free because it has to be funded. It is a decision by society and by the Oireachtas as to whether it is appropriate to fund something or not. We have the honour to be here and to be the people who decide on that. We use short-hand terms such as "free GP care" but we know it has to be funded. I believe it is absolutely something that deserves our taking steps to introduce.

I understand Senator Healy Eames's point that she agrees with universal access in theory. By extension, it seems she is making a distinction between agreeing with it in theory but not necessarily agreeing with it in practice. Our challenge, if we agree with it in theory, is to bring forward that policy in the way the Government has decided in the programme for Government and in its subsequent decisions in that regard.

I addressed the issue in regard to GPs and I agree with Senator Crown. Who better to make the point than he about the importance of advocacy and the professional independence and autonomy of doctors, general practitioners, medical specialists and others to do the job they do but also to be in a position to advocate on behalf of their patients, patient groups or on any issues they regard as important that should raise, whether in this House, outside it or anywhere else. I am a strong believer in that. I am also a strong believer that doctors and medical people should have the right to do that and should not be restricted in that regard. One can take whatever one wishes from what I have said but one can take it that it is certainly my view and that of the Minister for Health.

There is no intention to interfere with doctor-patient confidentiality. If Senator Crown is right that there is some sloppiness in the wording of the agreement - I am not quite sure where he finds that sloppiness - we can address it in the course of the engagement underway with the IMO.

In regard to Senator Colm Burke's questions on insurance cover, the draft contract includes provisions on warranties and indemnities. It will also be the subject of discussion with the IMO because it would want to address that with us. On the legislation in respect of a requirement to have insurance, I am advised drafting of that legislation is continuing. I hope we will be able to repot progress on that soon.

Senator Gilroy made a point, reflected in the remarks of other colleagues, that the very real concerns of general practitioners throughout the country must be respected and taken on board. Senator Healy Eames and others made that point also, with which I agree. However, things have moved on since some of the meetings to which Senator Healy Eames referred. I heard about those meetings, know a lot of what was said at them and have read what was said in the media in respect of them. Things have moved on considerably.

I spent some weeks negotiating an agreement with the IMO. I emphasise the agreement is not an agreement on the contract but on how we do business together.

We needed to do that, arising from the uncertainty and difficulty associated with the competition law environment. We have now secured an agreement with the IMO which will facilitate a good competition law-proofed way of engaging the State services with the general practitioners, GPs. I am confident that will facilitate a very good level of agreement between ourselves and the doctors, which is necessary, and I agree with colleagues on that. Senator Quinn said there should be negotiations on this and engagement with people. There will be. Such negotiations and engagement are under way.

It is very easy to fall into the trap of decrying and criticising bureaucrats. I understand the frustration people sometimes feel, not just with the health services. We need good people to administer our health services. Of course we need doctors and medical professionals but we also need people to administer the service and to work on issues such as the contract. There is overarching political involvement in it but there are very engaged, professional people in the Department of Health and the HSE who worked hard to put in place the draft contract and then listened to, and engaged with, the GPs and the doctors. I assure the Members of this House that is happening.

These people, who do a terrific job on this, are entitled to a little more support than they sometimes get. I am not necessarily talking about this House but more broadly. The quick dismissal of bureaucrats is often misplaced. It is not a question of gratuitously wanting to interfere in general practice or to arrive in the dead of the night to go through everything in the surgery to see what people are doing, to look around corners, correct GPs homework or look into their computers for no apparent reason. That is not what anybody wishes to do. There will be no interference with the professional autonomy of doctors, whether in regard to data or any of the other aspects of the contract. It is simply a case of getting it done properly and economically on behalf of the State. That is what we intend to do.

I agree with Senator Barrett’s point that GPs ought to be available outside what we normally regard as working hours. Most general practitioners will say that there is such a service. There are good cooperative services in most, if not all, parts of the country now. GPs are not confined to nine to five hours. They work at different times in the evening and weekends as well. I agree with him that it is right that we should go for practices of four or more GPs. The model of the sole practitioner, whether in an urban or rural area, is in decline for good reason. It is not economically possible to sustain that model. That is why we are developing primary care centres.

I was interested in Senator Barrett’s point about the edifice complex. One thing that saddens me about health care is that people talk about hospitals only, defending them against closure. I might be on the streets if I lived in a town where the hospital was going to close. I would love to see the politics of health care moving to advancing, and advocating for, primary care services in the community.

I was in Schull in west Cork to open a primary care centre a few weeks ago. This is transformative for a relatively remote area. People no longer have to make a 100 km round trip, whether to Bantry or somewhere else, to go to an acute setting for example, to have a wound dressed, or something else done that should be done in the community. It has a transformational effect on the way people access health care because having to get on the road and travel is one of the most stressful things for people who are ill and vulnerable. While Senator Barrett is right about the edifice complex, I would seek support for a different type of edifice, a small primary care centre that combines under one roof, GPs, physiotherapists, speech and language therapists, and all the other health care professionals collaborating and working together so that people do not have to go to the much bigger edifices. We can then transform our health care services in the way we want that to happen.

We had an exchange the last day we debated this Bill, about the universal aspect, of which Senator Barrett is at the very least sceptical. I respectfully continue to disagree with him on that point. We are an outlier, compared with any country in Europe or the Organisation for Economic Co-operation and Development, OECD, where primary care does not have the commercial barrier of requiring one to pay fees. We must remove the barrier of fees in primary care so that people do not have to go to the accident and emergency department in the hospital. We should do that universally, for all our citizens. We need to find ways to do and fund that as quickly as we can.

Senator Barrett said the GP service works well, and Senator Healy Eames and others pointed out that it is the one part of our health service that is working well, and asked why interfere with it. Taken in isolation I agree it is working well but the health system is not working well. We have to look to primary care as the engine of change in the health service. Whereas one can say without fear of contradiction that the GP service is working well, it has to change in order to help the rest of the system to work well. That is why we are pressing for the expansion of primary care. The broader system is not working well and primary care is the way to go to resolve so many of those issues.

I thank the Minister of State for his thoughtful and considered reply to my amendments. I understand the broad thrust of his not wishing to bind the hands of negotiators with legislation when circumstances can change. The negotiator in this case, however, is the HSE, an organisation of which there is a general feeling there needs to be enhanced political scrutiny. That is all we are trying to do here, to make sure that not only do we have civilian control of the military but we have political control of the civilian infrastructure as well. It is not inappropriate to set out broad guidelines about what the HSE can and cannot do within its contract. The HSE has a conflict of interest, not only does it run the general practice but also the hospital and other services. In fact, it runs a breathtaking array of services. It is quite staggering to see the breadth and scope of the services for which it is responsible.

In attempting to deal with high profile budget problems in some parts of the service, such as the hospital service, it is all too easy for it to push work aside onto other parts of the service. That is one of the things that I and my GP colleagues fear in terms of the carte blanche approach to what it can put in the contract. In effect, it can be prescriptive about services, tests and treatments which can and cannot be provided and it can ask GPs to perform services which it could be argued could be best performed in some other part of the public health service by public health nurses etc. That was the genesis of those particular objections.

I will press for a vote on the amendment on the gagging order. I feel strongly about that. The point needs to be made because it does not apply just in general practice or the health service. The country has suffered on multiple fronts because of a lack of whistleblower protection. We are told there will be enhanced whistleblower protection. In the first draft of the first contract offered to the GPs it was being suggested that somehow the essential nature of whistleblower protection would be undermined. It has to be enshrined in every Bill governing any part of our public service, that this can never happen. This is as good a starting point as any.

On a more general point concerning the Minister of State's questions about the management, the managers and the officials in the HSE and the Department of Health, I do not hold them individually responsible for the problems in the health service although I think they have collective responsibility.

As the largest vested interest group in the health service, HSE managers stand to lose most from true health service reform, as a result of which they would cede virtually all of their power.

The key problem is profound and relates to the culture of management and leadership. People in officialdom and politics used to tell me to be quiet about health policy because I knew nothing about it. In the memorable words of one senior civil servant in the Department of Health, I was just a technician and the civil servants were the people who knew how the health service should be run. To prove the individual in question wrong, I signed up to do a health care MBA to which I gave two of my precious middle years. I found this an extremely interesting and informative activity. The first lesson we learned in the first lecture on the first day of the first semester was the difference between management and leadership. The key problem we have is that we do not have much leadership in the health service. For example, there is a lack of an appropriate cohort or adequate number of full-time academic doctors providing intellectual powerhouse medical schools, rather than mere "degreemails", as is unfortunately the case at present. We have far too many medical schools per head of population. Many of them are also small and understaffed, with approximately one tenth of the number of full-time consultant level people employed in them as one would find in equivalent institutions abroad.

One whole side of what should be the leadership part of the equation of Irish medicine and health care is missing. In our hospital structures every single consultant is co-equal with every other consultant and there is no question of an individual being the leader of a department, exercising autonomy and trying to hire and fire or bring in people. We simply do not do this.

I do not mean my remarks to sound pejorative but the specialists in human resources, physical plant and procurement should deal with human resources, physical plant and procurement, respectively. Instead, however, the people who are in a leadership situation, the technical managers, default into leadership roles. This is the reason we have most of our current problems.

The people who run and provide the intellectual inspiration for a law firm are the lawyers, not some group of professional managerialists who regard the lawyers as technicians who merely interpret the law. That is the core problem. We need to develop a cadre of leaders in nursing, medicine and the ancillary areas who will lead the service and tap into the expertise of managers, while having their activities subject to appropriate civilian control. That is not the current position. The reason so much flak is rained down on those who manage the health service is that they are doing the wrong job. The core problem is that they are doing a job they are not trained to do.

I will press the amendment because it is a very important issue of principle. We will dispose of the others when they come before us.

I thank the Minister of State for his responses which have gone some way towards clarifying many issues that are being thrashed out. We have not yet been given full clarity, however.

I am a strong advocate of primary care, of which general practitioners form the backbone. The primary care system does not work without general practitioners. I built up a business case for a primary care centre in Oranmore for three years, during which time I was told one could have all the public health services and speech therapists in the world but it would not be of any use without buy-in from general practitioners. I want general practitioners to be on our side.

The Minister of State referred to theory versus practice. While I am fully in favour of the proposed measures in theory, how will they work in practice unless we have a sufficient number of general practitioners to deliver them? Does the Minister of State have a deadline by which he will make a decision on the contract? Is there a minimum number of general practitioners required to commence the roll-out and, if so, what is it?

It is great to hear that matters have moved on but I do not want an apartheid style system to emerge in the area of GP care for children aged under six years. Such a system was evident in BreastCheck for some time. I want universality and uniformity of service. The number of general practitioners needed to achieve this matters because if a child of under six years must wait seven days to interact with a GP for seven minutes, it will not be a proper service. Does the Minister of State agree?

I fully concur with the Minister of State on health promotion and prevention. I also agree that people will not make an appointment with a doctor to find out if they or their children could be candidates for diabetes if they must pay €50 to do so. However, there are other ways of rolling out these types of services. For example, we have rolled out screening programmes and developmental, sight and hearing tests in schools for many years. Having worked in the area of health promotion, I agree with the Minister of State that we must prioritise health prevention and promotion. To return to the basic point, how many general practitioners must sign up to the contract if a universal service is to be provided?

While I am pleased the Minister of State is willing to speak about the gagging clause, I share Senator Crown's view. Why would one want to hamstring a general practitioner who is acting for the good of a patient? The Minister of State is right to address this issue. He is also correct that it is not appropriate to manage negotiations on the contract from the Oireachtas. However, our job is to remove the unsavoury principles that underpin the negotiations and will prevent a deal being reached. I refer, for example, to the gagging clause and the provision prohibiting the sharing of medical records. Did the Minister of State indicate that the medical record will be sacrosanct between patient and doctor?

The Minister of State also indicated that a change in competition law will make it easier to negotiate with general practitioners. We must have clarity on whether that is the case. We require accurate facts and figures on the numbers of general practitioners who are willing to sign up to this contract. Otherwise we will have a theoretical framework that will never work in practice.

Amendment No. 10 refers to the modernisation of diagnostic services.

We are discussing amendments Nos. 1 to 7, inclusive.

I understand amendments No. 9 and 19 are included in the group.

General practitioners have informed me that their budgets are so tight, they are unable to replace obsolete equipment. The Minister of State is correct that we must shift our focus from hospitals to primary care and the community setting. To do this, we must help general practitioners to buy the diagnostic equipment they require to carry out X-rays in the community and procure the information technology that enables them to send X-rays to hospitals. If general practitioners are so hamstrung by the Government that they cannot sign up to the contract, universal health care for children aged under six years will not be implemented and general practitioners will not be able to sign up to the contract as they will not be able to afford the equipment they need. This is a catch-22 scenario. How many general practitioners must the Government have on side if it is to deliver a semblance of universality?

I will speak to amendments Nos. 9 and 10 in a moment but first I will not allow some of Senator Crown's comments to go unchallenged. He suggested the Health Service Executive has most to lose from a reorganisation.

It seems to be some sort of tautology or, at minimum, a circular argument. In the 30 years I worked with the health services, I have never been accused of being a defender of the HSE and I am one of its greatest critics. Nevertheless, Senator Crown's diagnosis of the problem at managerial level in the HSE does not really capture the entire picture. There are many other interest groups involved which have a special interest in maintaining the status quo and are required to do so by their members in many ways.

The managerial position in the HSE outlined by Senator Crown - with managers making decisions - is the reality but there are some clinicians who also make decisions. For example, in the mental health services, the clinical director rules the roost within the catchment area in which those services are delivered. I have spoken in the Seanad many times about the postcode lottery. If a person experiences mental health difficulties, he or she is required to go to the consultant in the geographical area in which that person lives. If the consultant in question is a good clinician that is great, but the consultant must also be a good manager. If the consultant is one of the two, the patient is in trouble, and if the consultant is neither, the patient is in real trouble. The postcode lottery maintains poor service within the mental health sector as there is no way to judge outcomes from one catchment area to another; the patient or service user has no choice only to avail of the services in a particular area. This is an illustration of my point about Senator Crown's analysis of the managerial problems within the health services and how the entire picture is not captured.

A legislative proposal that would provide a GP not be required to adhere to evolving and best practice would be problematic and undesirable. It is premature to put the provisions of amendment No. 9 into legislation when we are unsure of an outcome, and we do not even know the final agreement under the June framework. It would be not only premature but reckless and careless to insert a legislative provision in advance of knowing what a contract will ultimately contain.

Senator Healy Eames mentioned the Competition Authority. The Irish Medical Organisation was involved with proceedings with the Competition Authority and that agreement is in the public domain. It relates to the way in which the IMO can work in future, and the agreement is in the public domain because it was the subject of High Court proceedings. The Minister has clarified that there is consultation with the IMO, and the Department and HSE are anxious that an agreement could be reached. In fairness to the Department and the HSE over the years, they have worked well with general practitioners and there is no reason they should not work well into the future. As part of that working together, the Department and the HSE must take on board the concerns that GPs have, and I have no doubt that the Minister and the Department will take on board the concerns which were initially raised. It was unfortunate that the contract was published before consultation with the representative organisations of the GPs, and I am not sure it was the best way to deal with the matter. It caused problems and fear that there would be no going back in the terms of this contract. It was not the right way to deal with the issue and the Minister and the Department should take on board the mistakes made by putting this draft contract on-line at such an early stage, even before there was consultation with the IMO.

To clarify, the Competition Authority and the IMO have reached an agreement that is in the public domain. The Department is working within the terms of that agreement in trying to ensure we can get a contract with broad acceptance by the majority of GPs. Of course there will not be a contract agreed by 100% of people but the Department and the HSE are anxious for there to be full co-operation by all parties in the improvement of a comprehensive medical service, and particularly in trying to ensure the service is available for those under six. That is very important.

I thank Senators for their further remarks and contributions. It is entirely a matter for Senator Crown to press the amendment but I am sorry he proposes to do so. I hope he and others have heard what I have stated in respect of what has been termed a "gagging" clause. This is in addition to what I have stated outside the House and the Minister for Health's comments about our intentions and bona fides with regard to the matter. So be it.

There was an interesting discussion about conflict of interest, which was raised by Senator Crown and picked up by Senator Gilroy. Perhaps it is an issue for another day but I must question what people believe the "interest" is of the HSE other than the public interest. Perhaps it is an academic debate. It has been determined that the HSE is to be abolished, although we will still need people to manage our health services. People in the health services come and go; some retire and others come along to do the work. I am not fully sure what is the "vested interest", which was the phrase used. Perhaps that is just a difference between us.

Everybody would recognise that historically there is tension between practitioners and managers. I would not describe Senator Crown or any of his colleagues as mere technicians but nor would I put down people who do important work in the service as mere bureaucrats. It is a little facile for us to engage in that kind of phraseology or debate as it does not get us anywhere. We need both our administrators and professionals, and the challenge is to have the correct balance between them and ensure that professional autonomy, for example, and leadership is facilitated. I was very interested in what Senator Crown said about professional leadership. I am not as fully informed about the gap he sees in professional leadership and whether the system needs to address it in a better fashion. I might discuss it with him on another occasion, as there was much sense in his comments.

There is no question of being prescriptive with, for example, a HSE manager being prescriptive as to what test a doctor should appropriately implement for a patient or illness. That would be absurd and why would anybody think it would be remotely appropriate? Why would one think it is intended that the HSE should say that a particular test should be used or a doctor should engage in a particular fashion in respect of the care and management of a patient? That could not arise.

There is another issue pertaining to the debate of who makes decisions about health services. We were criticised by some practitioners for going ahead with legislation without having agreement from the medical profession. I must respectfully repeat the point that the question of policy and the distribution of resources allied to that policy is a matter for the Oireachtas and not a matter for the profession or any other group. I do not for a moment say the profession should not have an input, and it would have an elevated input because of its expertise, which I accept. The policy making must remain a matter for the Oireachtas as the distribution of a resource - whether in health care, education, justice or social protection - is a matter for a policy makers. It should remain as such, and I therefore do not accept that the drafting of legislation should be made contingent on the agreement of any vested interest or profession.

I say that in all generosity to them. The input, however, has to be respected and taken on board.

With respect to Senator Healy Eames, to some extent she is putting the cart before the horse. I am not going to speculate as to how many doctors will sign up to this contract. It is a voluntary question for anyone in any contractual position. No party can force the other party to engage in or sign a contract. The GSM system is founded on a contract between the system and the individual general practitioner.

That is not what I asked.

The objective is to get agreement.

Senator Burke made the point about the settlement agreement in the High Court proceedings. Separately from that, the framework agreement I have signed is not a settlement with the IMO in the context of litigation. That is an entirely separate matter. I have concluded and signed a framework agreement between the Department and the HSE on the one hand, and the IMO on the other about how we structure our negotiations and our engagement on all of these matters. The State was not involved in those proceedings. This is an agreement between the Department and the IMO to direct and manage-----

On a point of information, my question was about how many GPs the Minister of State needs to sign up to the scheme.

I am not going to speculate on numbers of GPs. Instead, I am going to encourage, in every way possible, the parties involved to conclude an agreement. I have every confidence in GPs and their representative body and I believe we will be able to deliver this service in the autumn with good will on all sides. I believe there will be a sufficient number of GPs to do so. There will be capacity issues in the system as we move on from the under-sixes that will have to be addressed. This will be done in the negotiations with the IMO.

The question as to how many will sign up to this is somewhat academic because we have not yet made a single contract offering to any GP yet. There is only a draft contract to drive the process but no actual contract has yet been sent out. We are some distance off this but we are getting closer.

If I may offer some friendly advice to the Minister relatively early in his ministerial career, a career which I am sure will be a long and a distinguished one.

The Senator might be too late.

He should not fall into the prevalent trap in history of misidentifying the public interest with the interest of a public body. Public bodies still behave in a corporate fashion for their own self-interest in all kinds of ways. The notion that uniquely in the whole tapestry of forces which shape our society that the only body of people capable of self-disinterest is the Civil Service is naive.

Amendment put.
The Seanad divided by electronic means.

To spare my colleagues across the aisle from the embarrassment of being bound and whipped on a Bill which has to do with gagging, I ask for a walk-through vote.

Before I call the walk-through vote I welcome the Mayor of Cork, Councillor Alan Coleman, to the Gallery.

Amendment put:
The Committee divided: Tá, 27; Níl, 26.

  • Barrett, Sean D.
  • Bradford, Paul.
  • Byrne, Thomas.
  • Crown, John.
  • Cullinane, David.
  • Daly, Mark.
  • Healy Eames, Fidelma.
  • Heffernan, James.
  • Leyden, Terry.
  • Mac Conghail, Fiach.
  • Mooney, Paschal.
  • Mullen, Rónán.
  • O'Brien, Darragh.
  • O'Brien, Mary Ann.
  • O'Donnell, Marie-Louise.
  • O'Donovan, Denis.
  • O'Sullivan, Ned.
  • Ó Clochartaigh, Trevor.
  • Ó Murchú, Labhrás.
  • Power, Averil.
  • Quinn, Feargal.
  • Reilly, Kathryn.
  • van Turnhout, Jillian.
  • Walsh, Jim.
  • White, Mary M.
  • Wilson, Diarmuid.
  • Zappone, Katherine.


  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Noone, Catherine.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • Whelan, John.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared carried.
Progress reported; Committee to sit again.

I would like to welcome Councillor David Gilroy, a brother of Senator John Gilroy, to the Gallery also.