[Speaking during Committee Stage of the Health (General Practitioner Service) Bill, on my amendment to remove a gagging clause on GPs. My amendment was voted through and will be part of the legislation.]
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.
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.
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LINK to Minister’s Reply:
http://oireachtasdebates.oireachtas.ie/debates%20authoring/DebatesWebPack.nsf/takes/seanad2014070900026?opendocument
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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.
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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. …. 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 Committee divided: Tá, 27; Níl, 26.
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Amendment declared carried.
