In the summer of 2004, Mr Fergus Hoban announced plans to develop 60 primary care centres around the country under his Touchstone model. However, just two currently exist, so what happened? Priscilla Lynch investigates
Back in 2002, Mr Fergus Hoban, a qualified pharmacist, brokered a major deal worth more than €100 million to sell the Unicare chain of pharmacies which he had founded and was Chief executive of.
Having made an estimated €23 million from the sale, Mr Hoban indicated he wished to continue working in healthcare and had plans to develop a number of multi-discipline healthcare centres.
The Department of Health’s 2001 Primary Care Strategy envisaged a network of primary care centres around the country which would revolutionise how healthcare services were delivered, with the majority of healthcare needs being provided within a community setting – so the time was ripe for entrepreneurial moves to develop such centres.
Mr Hoban met the Department of Health in late 2002 to explain his vision, and spent much of 2003 fine-tuning a very particular primary care centre (PCC) model, which he publicly launched in the summer of 2004.
The model
Under the Touchstone model, the company would develop a €500 million network of up to 60 purposebuilt, state-of-the-art PCCs across the country within six years, which would be within 15 minutes’ drive of over 70 per cent of the population.
Each centre would provide a multidisciplinary range of services, anchored around GPs, allied health professionals, diagnostic services and retail services, such as pharmacies.
Each centre aimed to attract approximately six GP tenants who would own their own suites, given at a substantial discount, thereby, according to Mr Hoban, remaining independent and autonomous.
Touchstone would work closely with interested GPs in developing the centres, bringing the facilities from inception through financing, design, site acquisition, planning, building, fitting, and operation to ongoing support.
The centres would be run by a trust, on which GPs would be the majority, and Touchstone would own and deliver an array of complementary healthcare services under four main headings – retail, paramedic, diagnostic and domiciliary care.
Early opposition
Despite praise for the concept of delivering such state-of-the-art primary care facilities to the Irish public, there was much opposition to the model from medical sources.
The IMO spoke out strongly against the model with then President Dr James Reilly (now Fine Gael Health Spokesperson) and then IMO GP leader Dr Martin Daly claiming the model would lead to the “creeping corporatisation of general practice”, disengage GPs from controlling the delivery of their services, and warned GPs not to be “seduced” by the model.
The Organisation encouraged GPs to set up their own centres and work with the HSE to roll out primary care teams, though Mr Hoban did contact the Organisation and have discussions with it.
The Irish Pharmaceutical Union also objected to the model, raising concerns about the monopoly location of pharmacies within the centres.
The IPU also claimed that such ‘super centres’ would be located on the outskirts of towns leading to the closure of smaller pharmacies within towns, though Mr Hoban denied this and said the aim was that the centres would be located in the centre of towns, at the heart of the community.
Mr Hoban gave interviews to the medical press in which he attempted to assuage doctors’ suspicions about his model and he also spoke about his model in detail at the ICGP’s Annual Winter Meeting (AWM) in November 2004.
“In summary, what the Touchstone model offers is a way for GPs to re-position primary care in the patient’s mind and in reality. It creates the context for the delivery of radically better, integrated service.
"It puts GPs at the centre, respects their autonomy and is structured so as to defend that autonomy for all time. And, for our client GPs, the real costs involved are very low,” he told GPs at the ICGP AGM.
Mr Hoban said he was not short of interest from GPs in pursuing the Touchstone model and claimed dozens had been in contact about potentially signing up to develop a centre.
Momentum
2005 was a successful year for the fledgling Touchstone model.
By the middle of the year, around 250 GPs were engaging with the company to develop primary care centres.
The first Touchstone centre, Riverside Medical Centre, opened in Mulhuddart Village, Dublin, in a blaze of publicity that October, being officially launched by Health Minister Mary Harney.
This particular centre, however, was not the typical envisaged Touchstone large-scale, newbuild model, but rather an 11,500sqft refit with four GPs.
However the centre was well received and served as a showhouse for interested GPs. Following the opening of the Mulhuddart centre, more GPs signed up to the Touchstone model.
By mid-2006 almost 320 GPs were reported to be working with the company, with site acquisition underway in 32 planned projects.
Another six centres (three in Dublin, three outside Dublin) were scheduled to be up and running in 2008, 14 new centres were due to be opened in 2009, and a more realistic projection of 60 centres were expected to be completed between 2011-2014.
Projects were confirmed for Carlow and Kilkenny and a number of locations in Dublin, including Drimnagh, Finglas and Dolphins Barn.
Further projects would be confirmed for Fairview in Dublin, Wexford and Kerry.
At this stage, Mr Hoban was reported to have invested around €4 million of his own money in the company, and he was also involved in Carr Communications, in which he became a significant shareholder.
In addition, the project received a major credibility boost when, amidst a number of high-profile appointments to the Touchstone Board, Dr Sean McGuire, then special GP advisor to HSE CEO Prof Brendan Drumm, and the man seen as the driving force behind the HSE’s plan to roll out 500 primary care teams across the country by 2010, left his HSE post in early 2007 to join Touchstone as Director of GP Client Relationships.
It had already been revealed the previous year that Dr McGuire was involved with a planned Touchstone centre for Carlow town with a number of fellow GPs.
His move to the private sector led to criticism of the HSE and calls for a “career quarantine” for individuals working in the public sector who left to go to similar roles in the private sector.
In addition, Prof Tom O’Dowd, respected Professor of Primary Care in Trinity College Dublin and leading primary care researcher, also joined Touchstone in mid-2006 as Clinical Director to advise on medical education and research for the centres.
Problems
Despite the level of interest in the Touchstone model and a relatively good start, problems started to emerge in getting the centres off the ground.
As is the case with many Irish healthcare projects, Touchstone found the planning process long, demanding and expensive.
A number of its projects ran into planning headaches, with appeals against planned centres in Dublin, Carlow and Tipperary during 2006, 2007, 2008 and 2009.
Sometimes planning permission was initially granted then appealed to An Bord Pleanála; other times, when permission was granted, expensive stipulations were attached.
A site in Carlow, which eventually secured planning permission from An Bord Pleanála in late 2008 and on which work had commenced, was damaged in a suspected arson attack in the summer of 2009.
A major six-storey Touchstone project in Drimnagh, Dublin, for which planning permission was originally applied for in 2006, was granted the go-ahead in 2007, appealed against to An Bord Pleanála and turned down in early 2008.
The project plans were then trimmed down and fresh planning permission was sought for a four-storey, 39,000sqft development last year, which was again objected to by some locals as being an excessive development.
The project was granted planning permission in March this year but was again appealed against to An Bord Pleanála. The project was eventually given the go-ahead last month.
Boom to bust
The property boom also played a major role in delaying Touchstone’s plans.
As property prices continued to climb at dizzying rates from 2004 to 2007 it became very difficult for Touchstone to compete for large, welllocated sites in big towns and cities, which were hotly sought-after by big developers for lucrative retail, hotel and residential developments.
It was estimated in 2007 that the 60 centres would cost €800 million, not €500 million as originally planned, and this new estimate was barely enough to keep pace with the property bubble.
“We just couldn’t compete with the developers. Often we weren’t even the second or third runner-up for a property; we were the sixth to seventh, so the property boom had a major impact on our plans, ” Mr Hoban told the Medical Independent.
“It was a very frustrating time for us. We couldn’t get the property we wanted for love nor money. It was Anglo Irish Bank money and we weren’t dealing with them – we had a lucky escape – we were dealing with English banks mostly, who were a lot more prudent.
"Having headed into this project in 2003, I saw site prices escalate to such an extent that it wasn’t viable to develop a primary care centre at those prices. We had to sacrifice a lot of our reputation and swallow our pride and sit on the sidelines.”
During this difficult period Touchstone also lost its GP Director Dr McGuire in seemingly acrimonious circumstances. It emerged in early 2009 that Dr McGuire had left the company.
At the time, Touchstone denied speculation that there were any outstanding legal issues between the two parties in relation to monies owed to Dr McGuire or regarding Dr McGuire pursing his own primary care centre projects.
“Touchstone reserves its position in relation to its clients and its intellectual property. Sean McGuire was paid in full by Touchstone,” a company spokesperson said at the time.
Dr McGuire has since gone on to set up his own primary care development company Prime Health (developed in February 2009), which is behind a large-scale 40,000sqft primary care centre in Carlow, which Dr McGuire opened in September 2009 and is also behind a major 50,000sqft centre, which is due to open in Killarney later this year.
Brighter future
Despite many setbacks, Touchstone is now firmly back on track, Mr Hoban told the Medical Independent.
It finally opened a second centre in Mahon, Cork, in February this year.
The centre is true to the original Touchstone model – 45,500sqft in size, with 91 practice suites and is able to accommodate 120 healthcare workers, serving an approximate population of 30,000.
It is anchored by nine GPs, involving three HSE primary care teams, and around 60 HSE staff currently, with the HSE formally due to move in with its allied health services by next January, said Mr Hoban.
“We’ve had a very positive response to the centre from the community … a lot of people are surprised by the quality of it,” he commented.
Speaking to the Medical Independent, one of the centre’s GPs Dr David Flynn, of the Silverdale Practice, said he and the other eight GPs are very pleased with the centre and so are their patients.
He said he would “absolutely” recommend coming together and pursuing such a model to fellow GPs, and praised Mr Hoban for his commitment to the project.
Dr Flynn acknowledged that a lot of work is involved in the project, and that meetings were held weekly for two years but the GPs were very involved with the development of the centre and “were consulted every step of the way”.
He hoped that the HSE would acknowledge what GPs were doing in developing such centres and support them. He remarked that patients had higher standards now and won’t just go anywhere to see a doctor.
Relationship
Mr Hoban added that the centre has already struck up a “good relationship” with the nearby new private hospital, the Cork Medical Centre, which was just formally opened earlier this month and is operated by Sheehan Medical.
In addition, Touchstone expects to open another one to two new centres within the next 12 months, though Mr Hoban was coy about the exact number of GPs currently involved, the number of centres the company is now working on, where exactly they are and how many Touchstone centres will ultimately open, saying that giving exact figures in the past had ended up burning the company when it ran into delays.
He did however say that the company is currently focusing on large-scale projects of around 40,000sqft in Dublin and Cork.
He welcomed the recent go-ahead for the Drimnagh centre after years of wrangling, while the company has also re-submitted plans for a centre in Rialto, Dublin.
Mr Hoban also maintained “historical” projects such as the one in Carlow will go ahead. The HSE is also pushing ahead, albeit slower than anticipated, with its primary care team network and wants about 200 PCCs.
Mr Hoban said that while the company is in discussions with the Executive, it is pursuing its own plans and has HSE involvement in some projects but not in others. He admitted that developing PCCs is “very difficult” and one “has to be passionate about it”, which he is. With the collapse of the property market, Touchstone now has a much easier task in acquiring desirable properties at more realistic prices.
“We will never get an opportunity like this again. We have a five- to seven-year run to do right-price deals and we will keep going as long as we feel there is a market there,” the CEO said.
Overall, Mr Hoban believes there is potential to develop 70 to 80 large-scale PCCs across the country, as well as a number of smaller centres, though he would not be drawn on how many of these centres could be developed by Touchstone.
For now, he is committed to getting existing Touchstone projects off the ground.
“Primary care is the future. If we can see a movement in improving the quality of care and providing chronic care management in the community then we will see healthcare costs reduce … It is vitally important that we get full-scale primary care teams and if we can have competition in the market between quality providers, that’s a good thing and patients will vote with their feet.”
How the touchstone model works
Touchstone offers a range of consultancy services to assist healthcare professionals to create their own primary care centre, which it says ensures that the process of creating the PCC progresses with minimum interruption to existing practices, while optimising the effectiveness of the centre and its positive impact on the community.
Consultancy is offered by an experienced team of professionals. This service is offered free of charge to those wishing to create their own PCC with Touchstone.
Property and infrastructure
Touchstone’s property team finds suitable sites and takes care of everything involved in developing a PCC. It manages planning, design, project management and full delivery of the completed PCC. Once the PCC is open, it continues to support the upkeep and management of the centre.
Financial and regulatory affairs
Together with its partners in KPMG and Miley & Miley, Touchstone says it makes sure that the financial deal makes sense.
It also ensures that healthcare professionals are fully briefed on all aspects of relevant regulatory matters such as health regulations, competition law and taxation.
Public affairs
Working with its partners in Carr Communications, Touchstone says it makes sure that all relevant stakeholders (e.g. community groups and local authorities) are aware of how the project is developing.
Touchstone says it also helps to facilitate discussions with the HSE about how the needs of the community are currently being met and how they may be met in the future with the assistance of the new centre.
Change management
Touchstone’s main consultancy practice is change management. For healthcare professionals it is likely that this change will be the biggest in their career and it says that is why it is there to help.
It provides a variety of services in this area that are specifically adapted to meet the needs of establishing a PCC.
Touchstone also assists with IT, recruitment, operational design and succession management.