I welcome the Minister and his officials to the meeting. Deputy Ó Caoláin's amendment has been ruled out of order.
Health (Provision of General Practitioner Services) Bill 2011: Committee Stage.
I wish to address briefly the essence of my amendment. Arguably, it is not all disallowable.
Will it be okay to talk about it when it arises?
It may be dealt with under the relevant section.
SECTION 1
I move amendment No. 1:
In page 4, to delete lines 9 to 13 and substitute the following:
" "relevant medical practitioner" means a registered medical practitioner—
(a) whose name is included in the Specialist Division of the register of medical practitioners established under section 43(2)(b) of the Medical Practitioners Act 2007, and
(b) who holds a current certificate of registration within the meaning of section 2 of that Act in respect of the medical speciality “General Practice” recognised under section 89(1) of that Act;”.
Amendment No. 1 amends the definition of "relevant medical practitioner" to ensure the general medical services contract is only opened up to fully qualified and vocationally trained general practitioners. The definition, as it stands, could have the unintended consequence of opening up access to doctors trained in specialist areas other than general practice. I propose to specify that doctors must hold a current certificate of registration within the specialty of general practice.
I propose to delete the clause "or whose name is eligible for inclusion, in the Specialist Division of the register" because there is no method of assessing whether a doctor is eligible for registration. A doctor is either registered or not. Hence, the deletion of the phrase is included in the amendment.
That was the critical difference. When preparing my notes, I wanted to hear the Minister's rationale. I have now heard what he has to say. Is the phrase "or whose name is eligible for inclusion" being removed because the substitute wording, "who holds a current certificate of registration", is equivalent? Is the Minister saying there is no circumstance in which an eligible person is not registered?
No. I am saying there is no method of assessing whether a doctor is eligible. People could apply stating they are eligible and subsequently be found to be otherwise, yet they would hold a contract. The provision should not have been in the existing legislation. The amendment is being tabled under legal advice.
From the Minister's experience, is there any form of eligibility other than the holding of a current certificate?
Not that I am aware of.
That was the key point. The exclusion struck me as the real difference and, therefore, I highlighted it. I will have to go by the Minister's better information on these matters. I will accept his amendment.
I appreciate that.
Amendment agreed to.
I move amendment No. 2:
In page 4, line 14, before "amended" to insert "as".
This is just a technical amendment recommended by the Parliamentary Counsel to ensure the terminology is in line with standard usage. It has the effect of inserting the word "as" in the definition of "relevant section". It will now read: " "relevant section" means section 58 (as amended by section 5 of the Health (Amendment) Act 2005) of the Health Act 1970;".
It is a grammatical correction.
Amendment agreed to.
Section 1, as amended, agreed to.
NEW SECTION.
I move amendment No. 3:
3. In page 4, before section 2, to insert the following new section:
2.-(1) Subject to subsection (2), a provision of any relevant agreement which has as its object or effect (whether in whole or in part) the limitation, by reference to an event whereby a relevant medical practitioner ceases to provide relevant services, of-
(a) the power of the Executive to enter into an agreement with one or more than one relevant medical practitioner for the purposes of the Executive performing any of its functions under the relevant section, or
(b) the power of a relevant medical practitioner to enter into an agreement referred to in paragraph (a),
shall be void in so far as that provision has that object or effect, as the case may be, and irrespective of the nature of such event.
(2) Subsection (1) shall not apply to a provision of a relevant agreement entered into before, on or after the commencement of this section in so far as the provision has the object or effect of causing a relevant medical practitioner to cease to provide relevant services (whether by termination of the agreement or otherwise) on reaching the age of 70 years or such other age as is specified in that provision.
I will not discuss the amendment in detail because it is very technical. It would be wiser to explain the rationale behind it. The amendment will replace the existing section 2 with a new section 2. The existing section provides that the HSE will be entitled to enter into a GMS contract with any suitably qualified and vocationally trained GP and will not be limited to granting contracts in cases where a contract holder has died, retired or resigned, or where the contract has otherwise been terminated. The revised section 2(1) contains a simpler and more comprehensive form of words. In particular, it provides that the HSE may enter into a GMS contract with any suitably qualified and vocationally trained GP, regardless of the reason another GP has ceased to provided GMS services. We do not want to obstruct properly qualified GPs from setting up practice.
The existing section would have had the unintended consequence of voiding provisions in the current GMS contract under which GPs cease to hold a contract on attaining the age of 70. The revised section ensures the age limit remains in place, although the HSE will not be precluded from extending contracts with GPs who have reached the age of 70 if local circumstances require it to do so.
The note to the amendment states: "Acceptance of this amendment involves the deletion of section 2 of the Bill." Perhaps this phrase is used for merely stylistic reasons but I ask the Minister to explain why it is used instead of "in substitution for", which is the phrase used in amendment No. 1. It is an unusual formulation.
This is the methodology followed by the Parliamentary Counsel. I acknowledge the Deputy's question in regard to why one phrase was used instead of another.
It is a question of methodology. I accept it is allowable but we have only reached the third amendment and already two different methods are used for substituting an entire section. I am just wondering why a consistent approach was not taken. In regard to the drafting of the Bill, I have never come across such difficult legalese to wade through. I have seen some heavy examples over the years but parts of this Bill were impenetrable despite its brevity.
We had a discussion earlier on registered doctors as opposed to those who are entitled to register. The explanatory memorandum states: "Section 2 provides that the Health Service Executive will be entitled to enter into a GMS contract with any suitably qualified and vocationally trained General Practitioner". Could one be a suitably qualified general practitioner without being vocationally trained, in which case the question of entitlement would arise? Is this phrase repetitious or is it required? According to my simple understanding of English, either one is suitably qualified or one is not. Is it necessary to add "and vocationally trained" to make the point?
All new GPs, and all new entrants into the GMS, need to be vocationally trained. If they come from another jurisdiction they should have been vocationally trained there if their qualifications are equal and accepted by the Irish College of General Practitioners. We have a shortage of GPs and we are seeking to fast-track training for a certain number of doctors who have been working as GPs for quite some time but never completed the prescribed training. It would be wrong to expect them to complete a four-year course when they are experienced and have already done much of the work. We provide a shorter two-year training course for these individuals but they are nonetheless vocationally trained.
It is important that GPs are vocationally trained. The colleges have been supported by the Government in turning general practice into a specialist discipline. Particular skill sets are required and general practice has become more complex. In the old days one simply put up a nameplate as a GP if one got fed up with psychiatry or surgery but it is now recognised as a different specialty. This is why the provision is included.
The Deputy may think it is overkill but I could say it is to be sure, to be sure. "Suitably qualified" implies vocationally trained but this makes it clearer.
We have a belt and braces Minister.
What does the Minister mean by vocationally trained?
It means that the individual has gone through a training scheme specifically designed for general practitioners.
What is involved in the training?
It involves the full gamut of work that GPs undertake. It is quite a while since I completed my GP training but I would have to have studied medicine, surgery, a portion of psychiatry, and obstetrics and gynaecology, among other subjects. New modules are being introduced and much of the training now takes place in general practice, which is better than being entirely hospital based. One of the major deficits in our training of specialists is that they lack experience of general practice. All GPs have experienced hospital practice by the time they go to the community but the reverse does not apply.
The Minister is correct that GP training is hands-on and patient centred.
Does this mean doctors have to be part of a scheme or can they take the training on an individual basis?
No, they must be part of a recognised scheme. They cannot self-train, as they did in my day when people did six months here and six months there before setting up practice. In the past one could set up as a GP after completing the intern year but clearly that was not a wise move and most people did not attempt it.
I accept the Minister's explanation. Legislation is all about interpretation and it is important to be clear. The bottom line is that he is seeking to remove any restrictions, implied or otherwise, on access to the GMS. Access to the scheme will not be restricted by replacement and we agree additional doctors are required. For this reason I support the amendment.
Amendment agreed to.
Section 2 agreed to.
NEW SECTION
I move amendment No. 4:
In page 4, before section 3, to insert the following new section:
3. - (1) A relevant medical practitioner who has entered into an agreement with the Executive shall be required to display a price list for his or her services in a prescribed manner and in accordance with such conditions as may be prescribed at or near the entrance to any premises in which he or she carries on his or her profession.
(2) A relevant medical practitioner who contravenes subsection (1) shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding €4,000.".
I tabled this amendment after reading the Bill. A similar provision was made in respect of dentists in previous legislation.
It provides that the relevant medical practitioners who enter into the agreement should display a price list. This would be welcome and make it easier for people to access services. They can present quite distressed and are then concerned about how much they might have to pay. I understand, however, that this might not be possible at present.
I thank Deputy Conway for tabling the amendment. I absolutely agree with the principle that prices should be displayed and that people should know what costs they are incurring when they visit a GP's surgery. However, there is a technicality here. It does not arise under this Bill because GPs in private practice would not be forced to do this and two laws would apply. The relevant authority is either the Medical Council or the Competition Authority. I am happy to give the Deputy an undertaking on foot of this that we will talk to them about bringing forward legislation or a statutory instrument, if necessary, to insist that GPs display their prices.
I thank the Minister. He made a comment about this previously, so we will keep a close eye on it and see how it progresses.
I commend Deputy Conway for bringing forward this amendment. I accept that this is something the Minister would wish to see in place and if this is not the appropriate route, I hope another will be found. On reading the proposal I was struck by the need to have, in tandem with what Deputy Conway argues for, a proper policing process in place. As we have said time and again, there are still GPs who are charging GMS patients for specific procedures or situations presenting. That is outrageous. If they have their price list displayed and if they endeavour to extract payment other than what is posted at the entrance to the surgery, it will give the patient encouragement and, perhaps, the strength to challenge it. The great problem is that people are afraid to raise the issue with their GP because the relationship, the dependency and so forth are huge on a human level. However, this is happening, particularly for blood testing and a range of other procedures that should be and used to be covered under the GMS.
Certain items are not covered by the GMS, such as insurance tests, driving licence tests, eyesight tests for driving and so forth. The blood testing issue is very contentious but my view on it is very clear. Where GPs are investigating a complaint or a symptom, these tests form part of that and it is part of their ordinary work. There is an issue around routine screening, which is not covered in the GMS. However, I believe the Croke Park agreement can address all of this. The agreement is very clear - there will be no pay cuts for increased productivity. If GPs insist on being paid for every new item of service, we will be looking at their fee structure and cutting it. If they are prepared to come to the table in the spirit of the Croke Park agreement and increase productivity through new methods of delivering care, that is a different matter.
Would the Minister include the driving licence for senior citizens in that? The State gives them a free driving licence when they reach a certain age. To get the certification to qualify for their licence, people who are genuinely enduring hardship are obliged to pay the money and cannot afford it.
That would be a matter for negotiation.
I know, but it is an anomaly that has been in existence for a long time.
Historically, I suppose the car was seen as an unnecessary luxury while nowadays it is seen as essential.
In the present economic climate it is difficult.
Another problem is that some people might just need to see a doctor to get him or her to sign a form. The person is in and out of the surgery in a few minutes but is still being charged €50. On the other hand, another person going to the surgery might require an examination and be with the doctor for half an hour but they are paying the same amount. It does not appear to be a fair system.
GPs should examine that. I have no right to interfere in their private arrangements as Minister for Health. I can only encourage from the sideline.
Is Deputy Conway pressing the amendment?
No, but I will keep a close eye on the matter. Some of the points that were raised are very valid in terms of the power imbalance that can exist for people who are very vulnerable and unwell and who do not know what their outgoings will be in those circumstances. Anything we can do to ameliorate that situation should be pursued. I hope the Minister will do so.
Amendment, by leave, withdrawn.
Section 3 agreed to.
Sections 4 to 6, inclusive, agreed to.
NEW SECTION
I move amendment No. 5:
In page 5, before section 7, to insert the following new section:
"7.—The Minister for Health shall cause to have carried out by or on behalf of the Department of Health, a study, once in every five years, to assess the need for general practitioners on a geographical basis and shall take all necessary measures to ensure that all communities are adequately provided with general practitioner services.".
In the run-up to Christmas and on our first serious legislative matter, the Minister sends me a "Dear John" letter refusing to accept my amendment on the grounds that it might involve a potential charge on the Exchequer. However, I understand that as we speak such an investigation or study is under way under the Minister of State, Deputy Róisín Shortall, and is due for completion later this month. That is welcome. The amendment seeks to ensure that we have such a study periodically in the future. We need a requirement on the Department to carry one out occasionally, and the amendment suggests that it be once every five years. I do not believe it would be an inordinate cost. It should be part and parcel of the existing work rota within the appropriate section.
The key point is that this Bill puts the general practitioner service on a market basis. In my view it opens it to the market. However, it gives no certainty about geographic location or addressing the current imbalance in the ratio of GPs to the per capita population in different parts of the country. In terms of international comparisons, we have 52 general practitioners per 100,000 of the population, while France has 164, Austria has 144 and Germany has 102 per 100,000.
Apart from the international comparisons, there is a serious imbalance within this jurisdiction, and the Minister is conscious of that too. The figures for GP distribution from the ESRI report in 2009, which I cited previously in the Dáil, show that Cork, Galway and Waterford are better supplied, with an average of more than 65 GPs per 100,000 of the population, while Clare, Offaly, Monaghan, Laois, Meath and Kildare have the worst ratios, with less than 45 GPs per 100,000. Consider the situation in Tallaght, on the outskirts of this city. I do not have the figures with me but my recollection is that there were less than 30 GPs for a population of approximately 72,000. That is a damnable situation. Huge areas of this city are poorly catered for, particularly north of the Liffey, in terms of a GP service. This is something that is not addressed by the Bill, but it must be addressed.
The purpose of the amendment was to ensure that on the basis of a reasonable turnover of time this study would be undertaken by the Department to help guarantee better distribution of GP services so there will be more equality of access for our citizens across the board. If I am not allowed to press the amendment, I ask the Minister to consider bringing forward an amendment on Report Stage to address this matter. We need to find a way to do it. We cannot force the issue but we can highlight the study time after time. We can look to other measures to help guarantee a fairer distribution of GP presence across the State.
Deputy Séamus Healy
I support Deputy Ó Caoláin. This was the main issue raised on Second Stage by most speakers in the Chamber. The amendment has been ruled out of order. I am not sure whether the issue can be addressed in the Bill. If it can perhaps the Minister will return with an amendment. We need to do something to encourage new practices to establish in areas which are not currently properly serviced.
Large urban areas like Tallaght are not the only ones affected. Rural areas throughout the country are very badly served by GP services. We have an opportunity in the Bill or through some other avenue which the Minister can come back with to encourage GPs to establish practices in large urban and rural areas affected by the shortage.
Legislation cannot be used to address out-of-hours service cover. Traditionally when people were awarded GMS contracts there was an obligation for some out-of-hours cover. Can that policy be continued? It is still an issue in some areas. We welcome the opening up of the GMS to all doctors. The issue of out-of-hours services is one which weakens the ability of the State to regulate.
I am very much in favour of evidence-based information. I said policies would be based on evidence gathered which stands up. I accept the bona fides of the amendment. It has been adjudicated by the Ceann Comhairle as being out of order as it would be a cost to the Exchequer. I would like to reassure the Deputy that the study will be ongoing and regular reviews will take place. We do not need legislation to make that happen. It is something which should be happening within our Department on an ongoing basis.
The points made by Deputies Ó Caoláin and Healy are terribly important. We need to know where the problems are and examine why they are there so we can find the best way to address them. It is worrying that some of the counties the Deputy mentioned are quite near the centre of the country. We will have to investigate the situation and find out why we are having difficulties attracting young doctors to those areas.
The Bill will address the issue of Tallaght in a major way. Any GPs setting up, particularly given that we will be introducing free GP care over the next five years and will extend in the next year to the long-term illness scheme, will see there is a good living to be made. They will realise that money is not just in private practice in leafy suburbs. The thrust of where we are going with our health service is that everybody will be treated the same. Large centres of population should be seen as a good place to set up practice.
However, I do not want to see a situation where there are a lot of single practitioners. I hope that GPs will come together in groups to provide a broader range of services. I refer to Mallow where three large practices, comprising nearly 17 doctors, have come together. It has what it calls a "fourth practice" which is a new range of services which it would never have been able to provide individually but as a group practice they can provide them to the local community. That is the way forward and is an excellent development for which I commend it.
I am equally as concerned as Deputy Kelleher about the out-of-hours situation. It is part of the contractual obligation and will remain so. We have to be realistic. We cannot expect doctors to work all day, all night and the next day and make decisions which are safe and sound. We do not allow lorry drivers to drive for longer than eight hours and should not ask medics to work such hours on an ongoing basis. Again the group practice comes into play.
We need tighter control over the people who are acting as locums at night. I have heard anecdotal reports of people being referred for lacerations to be sutured in accident and emergency departments which should have been sutured by a locum. There is too much variation. I thank Deputies for giving me the opportunity to send a loud message that we will be auditing out-of-hours services, not just in terms of patient satisfaction but in terms of procedures which were not done but could and should have been. These audits will be carried out by clinicians.
The day of taking the easy way out and sending a patient down the road to an accident and emergency department has to end. GP out of hours services have huge satisfaction ratings but some areas have problems which need to be addressed and we will address them. Out of hours services will be part of the contract arrangements in the future.
I thank the Minister and the Chair for allowing me to elucidate on this proposal. I heard what the Minister said about ongoing changes. I said the ratio in Tallaght is under 30 but I have checked my notes and it is 24 for a population of 71,000, which is very worrying. The Minister's message is very important.
He should not close off the idea in his head that any amendments might not be appropriate in this instance. I appeal to him to reconsider that view and use the time before Report Stage to see whether something can be done in terms of encouragement, direction or whatever. It would be a pity to let this drift on and not address it in a substantive way within the Bill. If the Minister came forward with such a proposal I have no doubt we would all support it.
I will take that on board. We will use the time afforded to us to explore whether a provision can be included or at least alluded to in some way to the effect that it be an ongoing duty of the Department to constantly review the manpower situation, particularly in general practices. I thank everybody for their co-operation.
The Minister is being premature.
I do not want the wrong message to go out from the committee. General practice has proven itself to be fantastic value for money and of real value to patients. GPs treat 100,000 or more people a day. We treat approximately 3,500 people in our accident and emergency departments. A 1% shift from general practice to emergency departments creates problems and a 5% shift would create a fiasco.
I fully value what GPs are doing and commend them for the fact that, unlike the secondary care service in our hospitals and despite there being two different payment methods for private patients and medical card holders, no two-tier system has evolved. People are treated the same on a same day basis.
I thank the Chairman and committee members for their co-operation and support for the Bill. I wish all concerned a happy Christmas.
I thank the Minister and his officials for being here today.
Amendment, by leave, withdrawn.
Section 7 agreed to
Section 8 agreed to.
Title agreed to.
Bill reported with amendments.