Are the stars aligning to ensure that the long-awaited shift to primary care finally transpires? Niamh Cahill investigates
"Making the decisive shift of the health service to primary care in order to deliver better care close to home in communities across the country is paramount… I don’t want to just talk about making this decisive shift; I want to make it a reality.”
These were the words of Minister for Health Simon Harris at the Primary Care Partnership Conference in Croke Park recently.
Minister for Health Simon Harris
Like many health ministers before him, Minister Harris believes that a health service grounded in primary care is the way forward.
But as the Minister told delegates, “the key challenge remains how to translate an internationally-validated approach to the delivery of primary care into the specific professional, organisational policy and resource context in Ireland”.
This country has been hearing for over a decade about how plans to treat patients at the lowest level of complexity — ie, in primary care — were going to transform our healthcare system.
But despite several plans and many promises, a lack of investment in resources and services, along with the absence of costed proposals and targeted implementation plans, have meant that not much has changed to improve patient access to services and to keep patients out of hospital.
But could this be about to change?
Negotiations are finally underway on a new GP contract, a further 135 primary care centres (PCCs) are due to open within the next three years, while the Oireachtas Committee on the Future of Healthcare is emphasising the need to shift services to primary care settings.
Why primary care?
There are many well-documented reasons why primary care is vital for the delivery of an effective, high-quality healthcare service.
The IMO, in a recent submission on GP capacity issues to the Joint Oireachtas Committee on Health, noted research by the late Dr Barbara Starsfield, an American paediatrician, which found that “increasing the supply of GPs is associated with better health outcomes, lower rates of all-cause mortality, lower post-neonatal mortality rates, lower mortality rates from stroke, lower numbers of people reporting fair-to-poor health and higher life expectancy.
“Good patient-physician continuity is also associated with time-saving, less use of laboratory tests, fewer referrals to secondary care and lower healthcare expenditure.”
The establishment of a more primary care-focused healthcare system is also becoming more urgent, due to an ageing population, growing prevalence of chronic diseases and continued increases in attendances at hospital emergency departments (EDs).
The ICGP has pointed out the inequalities that exist in our current healthcare system, which are compounding matters.
“Inequality is built into hospital care, with privately-insured individuals over-medicalised in a fee per item model, and public patients placed on long waiting lists for essential services,” the College outlined in a submission to the Joint Oireachtas Committee on Health.
More than half a million patients are currently on waiting lists seeking inpatient and outpatient care.
In its submission to the Oireachtas Committee on the Future of Healthcare, the NAGP said the current system is failing “because it is orientated overwhelmingly towards expensive and frequently ineffective engagement with episodic illness but fails to manage the co-morbid patient, whose numbers are rapidly increasing. The relocation to community care will improve this situation dramatically.”
But for many patients, a hospital ED marks their first contact with the health system.
Long waiting lists for access to diagnostics and consultant services means that patients are sent to EDs to get into the system.
This has been particularly evident for vulnerable adults and children with mental health difficulties. In many cases, there is no place for them to go to access care, apart from the hospital.
Since 2000, total healthcare expenditure in Ireland has nearly trebled, from around €6 billion to nearly €20 billion in 2014.
Some commentators believe Ireland is spending enough on healthcare and changes in how this money is spent is required to deliver a more efficient, primary care-focused healthcare system.
In its submission to the Oireachtas Committee on the Future of Healthcare, Alpha Healthcare Ltd, which provides support services to healthcare professionals, GP practices and PCCs, highlighted Ireland’s healthcare spending.
“Ireland tops the EU table for percentage spent on health. CSO data published in 2015 showed we paid €18.4 billion on health in 2013, which was just above 12 per cent of gross national income. This was considerably more than the 9.2 per cent average spent on health by other OECD members,” its submission stated.
According to the HSE, €764.8 million was spent on primary care in 2016, compared to €773 million that will be expended this year.
This does not include spending by the PCRS, which amounted to over €2.4 billion in 2016, spending on local demand-led schemes, social inclusion and palliative care, which all also fall within the HSE Primary Care Division.
The Primary Care Division received an allocation of €3.8 billion this year.
On specific spending on general practice alone, Ireland does not fare well.
The IMO has pointed out that Ireland spends 3 per cent of the health budget on general practice, compared to 9 per cent in the UK, with this figure to rise to 11 per cent in the UK in the near future.
The Organisation has also highlighted that €160 million has been removed from general practice via FEMPI (Financial Emergency Measures in the Public Interest) legislation — all at a time when Government promised to invest more and not less in primary care, despite the challenges of an economic recession.
If Ireland is to make a ‘decisive shift’ to primary care, it is clear that more will have to be spent on this area.
The NAGP believes that at least €500 million every year, for the next five years, is required to effect this transformation.
GPs, the HSE and Government have cited the lack of a modern, functioning GP contract that addresses current work practices as a barrier to primary care development.
The ongoing negotiations on a new contract have been referred to by the HSE as a reason as to why some primary care developments are stalled — for example, the General Practice Minor Surgery Project. It is understood that no further development will occur until a new GP contract is in place, despite its success and the view that hospital day case lists could be reduced by up to 32 per cent through its expansion. It is unclear whether a lack of money to roll-out the project is the actual reason behind it being stalled.
Contract negotiations are at an embryonic stage and developments will occur on a phased basis, it is understood.
ICGP Chair of Communications, Dr Mark Murphy, told the Medical Independent (MI) that a new GP contract is urgently required.
In particular, he raised the issue of GP workloads in nursing homes. He said the current contract is insufficient to meet the workload.
Dr Mark Murphy, ICGP
The contract will also have to address many other areas, such as chronic disease management, out-of-hours care and primary care team (PCT) working, to give just a few examples.
Mr Kevin Beary, Healthcare Director at Bartra Capital Group, a company involved in the development of primary care centres (PCCs), said that a new GP contract is critical.
“The GPs have had a lot of genuine issues that haven’t been dealt with and have been building up for a long time, so they weren’t incentivised to co-operate with the HSE on things like primary care. It’s a quid pro quo. The HSE has now recognised that we need doctors in primary care centres and doctors need to have their contract modernised.”
In 2016, the Oireachtas Committee on the Future of Healthcare was established to agree a 10-year plan for the health service, to identify a pathway towards a universal, single-tier health service and to achieve consensus on a new healthcare model, based on need.
Its final report is due this month, but some healthcare commentators have told MI they believe the report will be a whitewash, as proposals will not be costed, like several previous well-intentioned plans.
Without resourcing and a strong implementation plan, there is a real risk the Committee’s work will become another report left sitting on a shelf, according to some healthcare professionals.
The fact that the forthcoming report will not be costed is a “big problem”, said Co Kerry GP Dr Eamonn Shanahan. He said attitudes among all stakeholders also need to change, noting that many plans are already in place but need universal buy-in to be effective.
Dr Eamonn Shanahan
A huge barrier to the development of primary care has been the lack of investment in new staff by the HSE and Government.
There have been problems hiring staff due to a lack of applications and the recruitment embargo. However, it is evident the HSE needs more staff to improve access to primary care.
The HSE and Government also need to place a greater focus on the retention of Irish primary care health professionals, with many GPs and nurses leaving for more attractive positions in other countries.
In 10 years’ time, the GP shortage will be in the order of 1,000, according to the ICGP.
Data released via Freedom of Information shows that 636.89 whole-time equivalent (WTE) primary care development posts were created by the HSE between 2013 and 2016 at a cost of €39.2 million.
In 2013, 264.5 primary care posts were allocated, but to date only 255 posts have been filled, the data shows.
The HSE said: “9.5 posts remain unfilled and recruitment is ongoing” — some four years after the posts were funded.
The unfilled posts relate to general nurses and public health nurses in three community healthcare organisation (CHO) areas.
In 2013, posts focused on primary care teams and included positions such as public health nurses, registered general nurses, occupational therapists, physiotherapists and speech and language therapists.
In 2014, development posts were allocated within palliative care services only. Some 84.19 posts were allocated in Cork and Kerry and Dublin north city and county.
Some 75 development posts were granted in 2015, including 11 chronic disease management posts, six medicine management posts within the PCRS, 20 posts within palliative care services, 11 Winter Initiative posts, one social inclusion addiction services post and 19 Children First posts. But seven of these posts remain either unfilled or were due to be filled in early 2017.
Last year, 213.2 posts were filled but five of these posts have yet to be filled, the data reveals.
The posts for 2016 included 49 chronic disease management primary care development posts, 39.7 palliative care service posts, 34.5 social inclusion addiction services for homelessness and drug and alcohol services positions, 84 posts for speech and language therapy initiatives within PCTs, and six Individual Health Identifier project posts.
Between 2013 and 2016, 584.39 WTE staff were employed within the HSE, while 52.50 WTE staff were employed within voluntary organisations funded through service level agreements (SLAs), the data notes.
Primary Care Centres
The 2001 primary care strategy set in motion plans to develop PCCs, along with the implementation of 400-600 PCTs. In later years, plans were made to develop 200 centres.
Development was slow and centres only began opening in 2009. In the same year, the HSE planned to open 50 centres by the end of 2010, but did not achieve this.
Mallow Primary Healthcare Centre opened in 2010 and was the first centre in Ireland to have GPs and HSE services working out of the same location.
The entire country was mapped into 530 PCTs in 2009. Currently, there are 484 teams nationwide covering the entire population, according to the HSE.
Some 99 centres have been built to date, with a further two (perhaps three) to become operational in the very near future, MI understands.
“There are 37 locations where primary care infrastructure is under construction or at advanced planning and a further 47 locations are at preliminary stages of development. Taking account of the above, 17 centres are expected to open in 2017 and 11 in 2018,” Minister Harris told delegates at the recent Primary Care Partnership Conference.
That’s a further 84 locations on top of the 99 centres already open. Centres are being developed via PPP (public-private partnership), capital funding or lease agreement.
After initially announcing the development of 20 centres via PPP in 2012, it was decided that just 14 centres would be developed, using €115 million in funding. The first of the PPP centres are due to open in the middle of this year after contracts were finally awarded for the work in 2016.
According to a Department of Health spokesperson, the PPP contract period will last for 25 years.
“The PPP company will deliver the 14 primary care centres and will be responsible for providing facilities management services only. The HSE will pay the PPP company a total annual unitary charge payment of circa €17 million, in monthly instalments. At the end of the 25-year contract, the centres will be handed over to the HSE, which will become responsible for the facility management services provided by the PPP company,” the spokesperson stated.
Mr Beary of Bartra Capital Group told MI the HSE plans to progress a further 135 centres within the next three years and is targeting a total of 350 centres nationally.
The Bartra Capital Group is developing and acquiring PCCs and nursing homes.
Since mid-2015, the group has been acquiring, developing and tendering for new HSE PCC projects and currently has about 30 active primary care projects valued at about €200 million.
One of its primary care centres is due to open shortly — a large centre in Bray.
“Where we see a deficiency in the market [where] the Government can’t afford to fund the capital element of the project themselves, but they’re prepared to support it on a long-term basis, then we will build and get planning and retain the assets but they will participate directly or indirectly through rents,” Mr Beary said.
A number of changes have occurred in recent times to help bolster primary care development.
“The doctors, in my experience, are now a lot easier to convince to go into primary care centres than they were three or four years ago,’ Mr Beary noted.
“There has been a lot of progress made with GPs in the last four-to-five years because of the problems with funding, getting banks to fund them… The GPs who were previously resisting going into centres are now finding that it actually is a way of protecting their practice because they will gain access to modern facilities that they don’t have to pay for. When they do move in with the HSE, they usually find there is a requirement to grow the practice because the HSE creates additional footfall as well.
“The HSE had to completely re-engineer the 35-year lease to make it more institutional/bank friendly and they’ve done that and now it works very well.”
The HSE, doctors and private sector are now working together in terms of PCC development, Mr Beary believes.
“It’s taken a long time but the rate of acceleration of the projects that they’re planning, the next 135 locations, we’ve seen in the last six months a huge focus on the HSE Estates to drive out and accelerate the tender processes for all of these.
“We’re also seeing the tender rules, qualification rules, getting tougher. In quite a lot of instances, people who got awarded tenders by the HSE never delivered because they either didn’t have the money or the expertise, so as a result of that the current tender process is much more rigorous for people to get through.”
To advance development, the HSE has also removed the lease requirement for specific GP numbers in certain locations.
Mr Beary explained that the development market, in terms of the players involved, has become more competitive. There is now a lot of foreign interest in centres.
Primary Health Properties (PHP) and Octopus Healthcare — both UK companies — have been funding and/or acquiring built assets in Ireland, Mr Beary said.
Glencar Healthcare — a company set up by former HSE CEO Prof Brendan Drumm and former HSE Head of Estates Mr Brian Gilroy —recently took over the management of PCCs in Wicklow and Mayo.
Separately, there are a small number of players that take the development risk and come into projects at an earlier stage and negotiate the leases, including Bartra, Mr Beary said.
The NAGP is eager to introduce Primary Care Resource Centres (PCRCs) in Ireland, essentially centres of primary care with diagnostic capabilities that do not house GP services.
According to the Association: “The current primary care centres only benefit a small number of GPs and patients. If re-designated as ‘resource centres’, they can serve as diagnostic and service hubs that support patient-focused care with full engagement of all local GPs.”
Mr Beary, however, does not think the centres would work in Ireland, as having GP practices disconnected from a centre creates difficulties, in his view.
“I think if you have them [GPs and HSE services] in two separate locations, it doesn’t work. That’s been our experience.”
Mr Beary is also not of the view that HSE plans for 135 centres in the next three years will occur within this time frame, because of planning difficulties and legal issues. He said five years is a more realistic time frame.
The rise in land costs is also serving as a barrier or stumbling block to PCC development via operational lease.
Higher land costs for developers are leading to higher rents for the HSE — an issue that must be factored into budgets.
New centres establishing in locations where GPs have already developed their own centres is also causing friction between the HSE and GPs.
In its 2015 submission to Indecon on a Review of Potential Measures to Encourage the Provision of Primary Care Facilities, the IMO warned: “Where doctors have developed their own centres, it is inappropriate that the HSE would simply build an entirely new centre without giving thought to the investment and development already undertaken by a GP in an area. This has happened in areas of the country already and has had a negative effect on both the investment of the GP and on the relationship between doctors in the area.”
In fully-functioning PCTs, patients with complex needs are having their cases discussed by multidisciplinary team members and are benefiting from a more comprehensive approach to care.
PCT meetings usually occur monthly, sometimes more frequently, and there is evidence of PCTs functioning well, within and outside of PCCs.
However, Dr Murphy believes establishing centres alone is not the answer.
“You can invest €10 million in a massive building and not one extra patient will be seen. Not one. I think that’s really unfortunate,” Dr Murphy said.
He believes there has been too much focus on premises and centres and the physical co-location of PCT members when discussing primary care.
“There is an over-focus on the built premises, primary care centres… If we’re also going to increase the workload with more chronic diseases being managed within the general practice setting, I think the existing premises will have to be supported primarily.”
He stressed that people deliver healthcare and that proper governance of PCTs is required, with GP time funded.
“There are clear examples of functional team-working where all the members of a primary care team, including the GPs, are located under one roof, and there are also examples of functioning primary care teams where they are not.”
Dr Shanahan told MI that changes in primary care have made a huge difference in his area, despite GPs not being co-located with a centre.
“We are in a much better place now than we were 10 years ago…access to services in the community has improved,” Dr Shanahan said.
“Ten years ago, we did not have access to services like community physiotherapy, speech and language therapy, occupational therapy. The nirvana would be a network of primary care centres across the country but this doesn’t exist…people are more important than the place.”
A recent paper in BMC Family Practice titled Do Primary Care Professionals Agree About Progress With Implementation of Primary Care Teams: Results from a Cross-Sectional study, looked at PCT implementation in Ireland.
It concluded that primary care professionals and GPs agree that there is limited PCT implementation.
“Respondents identified resources and GP participation as most important for effective team-working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team-working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists, though GPs rated it as less important,” it highlighted.