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“There is a disparity in the level and frequency of medical cover being provided by GPs to GMS patients in nursing homes… the current arrangements are no longer adequate to meet the needs of patients or nursing homes.”
These were the words of Minister for Health Simon Harris in response to a parliamentary question recently posed by Fine Gael Senator Colm Burke on the subject of GP care in nursing homes.
Minister Harris went on to state that these issues would be addressed in the context of a new GP contract.
“I am hopeful that agreement can be reached in the coming months and that priority service developments can start to be introduced during 2018,” he said.
However, an agreement has yet to materialise and many believe it may be 2019, at the least, before a new contract is delivered.
In the meantime, the healthcare arrangements for one of society’s most vulnerable cohorts remain “inadequate”, as the Minister has admitted.
But what exactly are the arrangements in place and how are they negatively impacting patient care in nursing homes?
Ireland’s elderly population is rising. By 2041, there will be 1.4 million people on the island of Ireland aged 65 and over — three times more than the older population in 2012.
In 2016, a Department of Health report noted that “our population aged 65 years and over is growing by approximately 20,000 each year and is projected to increase by over 110,000 in the next five years”.
This cohort commonly has more multimorbidities than the rest of the population and therefore, their healthcare needs are more demanding.
Polypharmacy is most common in the elderly and these medications need to be reviewed and checked regularly by healthcare professionals.
If a person is aged over 70 and lives in Ireland, they are entitled to register for a GP visit card, which means all GP visits are free of charge.
But the ‘catch’ is that you must be able to access a GP and increasingly, access for nursing home residents is becoming more difficult.
Dr Rita Doyle
There are many reasons why access to GP care in nursing homes is in peril and many more reasons why it is affecting some regions more than others.
Firstly, the difficulties plaguing general practice are having a major impact. Data from the HSE (as of 1 July) showed there were 26 vacancies for GMS posts nationally.
Ireland has 64 GPs per 100,000 of the population, which is lower than the OECD average and compares to 120 per 100,000 of the population in Australia.
Some 36 per cent of GPs are aged over 55 and 20 per cent of GPs who emigrate do not return. An ICGP survey showed that 66 per cent of GP trainees plan to emigrate.
According to ICGP President Dr John O’Brien, a trend is emerging where established GPs are leaving Ireland, while others are resigning their GMS lists to work exclusively in private practice.
“You are beginning to see that emerge, in small numbers, but it is beginning,” Dr O’Brien warned.
When a person enters a nursing home, they may move some distance from their original GP, triggering a change in GP.
In many areas, informal arrangements have existed between GPs in instances like these, where a neighbouring GP assumes the care of the patient in a reciprocal arrangement.
In many public long-stay units, GP medical officers are contracted to provide care in public nursing homes.
But this is changing as more medical officers retire and difficulties continue in recruiting GPs.
The problem has become so acute in nursing homes, particularly in Dublin and the surrounding counties, that the HSE has begun assigning nursing home patients to GPs — a move not witnessed in many years.
Private nursing homes in the Dublin region are paying five figure salaries, and in some cases reportedly six figures, to GPs to look after the care of their residents as GP access becomes more strained.
All nursing home patients continue to nominally receive healthcare from a GP, but as workloads increase and GP recruitment difficulties continue, the frequency of GP visits is lessening.
It is also important to note that, in 2010 under FEMPI, the Government introduced a 50 per cent reduction to the capitation fee in respect of patients aged 70 years or more who reside in a private nursing home for continuous periods in excess of five weeks.
Several public long-stay units owned and run by the HSE have historically employed GP medical officers to care for the medical needs of patients.
The contract for medical officers is much older than the current GMS contract and dates back to around the 1950s, it is understood.
There are a dwindling number of medical officers in Ireland and increasing difficulties in hiring new medical officers.
The post is not well remunerated, according to GP sources, and the heavy workload associated with the role is a deterrent.
In the past, such public units were more akin to “social housing units”, one GP told this newspaper. But today, they are home to an increasingly elderly population with complex multimorbidities.
The role has become so complex and demanding that GPs now believe it is a semi-specialist area that requires a specific skillset.
It is understood there are about 80-to-100 medical officers nationally (the HSE failed to provide a response on the issue by press time). However, this unconfirmed figure is set to fall in the coming years, as many medical officers are nearing retirement.
Some medical officers are technically retired but still in post, as there is nobody to replace them.
The feeling among established GPs is that if new GPs are to be attracted to the role, remuneration will have to increase. But a new contract for medical officers will not occur until a new GMS contract is designed.
Regina House Community Nursing Unit in Kilrush, Co Clare, is currently trying to resolve its own “medical governance” issue.
In June, the HSE invited GPs in the area to a meeting to explore governance options in Regina House, with a view to ensuring “safe practice and best outcomes for residents”.
But a meeting scheduled with local GPs for 25 June did not go ahead, as the HSE was advised that none of the GPs in the area would be attending.
“The HSE is trying to recruit a part-time medical officer for Regina House and have sought input and suggestions from the local GPs. A meeting is being arranged with Shannondoc with a view to exploring other options. The situation is being kept under constant review,” a HSE spokesperson told the Medical Independent (MI).
Meanwhile, in Tipperary, the HSE is trying to fill a medical officer post at St Patrick’s Hospital on a permanent basis. To date, the post is filled in a “temporary capacity” only.
A GP GMS list in Thomastown, Co Kilkenny, which heretofore included cover of nursing home patients by the previous GP, also remains vacant.
“The vacancy in relation to a GP in the Thomastown, Co Kilkenny area, has been advertised and the HSE/South East community healthcare services are processing applications in its respect,” according to the HSE’s spokesperson.
Reports emerged last year of GPs receiving notices from the HSE assigning nursing home patients to their GMS lists.
But a number of GPs across the country are no longer accepting patients due to the ongoing crisis in general practice and they have resisted such moves by the HSE.
Under the GMS, a nursing home patient can be assigned to a GP, but this does not oblige the GP to provide nursing home duties, it is understood.
To date, the practice seems most common in Dublin and surrounding counties.
Mallow GP Dr David Molony told MI that the care of ill nursing home patients represented a “serious problem”.
The management of these patients in nursing homes could be improved through the creation of a proper contract for care, Dr Molony said.
“There is a lot of waste in nursing home care because people don’t have the time to manage prescriptions, for example,” he said.
“The polypharmacy issue needs review. There are large savings to be made through formal reviews and formal structures here.”
He criticised what he described as the “over-regulation” of nursing homes, where nurses cannot act as they should due to stringent rules. He said the end result is that everything is passed on to the GP.
Dr Molony said the practice of assigning nursing home patients to GPs had not occurred at his practice to date. He added that research showed GP visiting rates were higher in nursing homes than in the community.
NAGP President Dr Maitiú Ó Tuathail called on the HSE to stop the process of assigning nursing home patients to GPs in an attempt to improve cover.
“It’s unfair and isn’t working,” according to Dr Ó Tuathail.
“The workload involved in caring for nursing home patients is enormous and this is not reflected in the current level of remuneration for GPs. Much of the work that GPs are required to do is not part of our current contract, from filling in cardexes, to episodic medication reviews.
Dr Maitiú Ó Tuathail, NAGP
“The care of patients in nursing homes will specifically need to be addressed as part of a new contract. It requires reform so that GPs can give these patients the level of care that is required.”
He said the situation represented another looming crisis in general practice for which the Minister and his Department have no plan.
“The fact that GPs cannot give intravenous medications to nursing home patients to keep them out of hospital [as IV medications are not covered under the GMS] really says it all — these patients need to be referred to the ED to receive the IV medications that they could receive in the nursing home. Surely this is complete insanity in a time of ED overcrowding, a trolley crisis and a bed shortage in hospitals.”
He added: “This problem will not be solved by bolting STCs [special type consultations] onto the current outdated contract. We need a dedicated section in the new contract which covers all aspects of care required by nursing home patients and which provides GPs with the adequate level of resources to provide that care safely and to the standard required. This will also address the difficulty in recruiting medical officers to cover nursing homes.”
He said the NAGP will meet with Minister Harris in September to discuss “lack of progress” on the GP contract and urge him to take action.
Earlier this month, the Association said it had received assurance from the Minister’s office that it will be included in revived GP negotiations. “Time is running out and the patience of GPs has long expired,” said Dr Ó Tuathail.
IMO GP Chairperson Dr Pádraig McGarry said the issue of nursing home care is among those included in GP contract negotiations between the IMO and Department of Health.
However, Dr McGarry said the topic was not part of any present discussions and a resolution was “not on the horizon”.
There is no “plan B” and nursing homes are dependent on the goodwill of GPs to provide services, he argued.
Dr Padraig McGarry, IMO
Recently-appointed President of the Medical Council, GP Dr Rita Doyle, previously drew attention to the fact that by April this year, she had visited a 75-year-old nursing home patient 14 times.
“What good value I am to the State, who will not pay me a viable wage — who will replace me?” Dr Doyle questioned in a Tweet.
Public vs private
Some GPs believe practical and staffing deficits in private nursing homes are contributing to the problem, as many private nursing homes are understaffed and existing staff are inexperienced in respect of handling patients’ healthcare needs.
GPs have complained of receiving numerous and oftentimes unnecessary calls from inexperienced staff with regard to patient care in nursing homes, which one GP said can be “majorly disruptive” to their daily working life.
The issue of GP care for nursing home residents is now reaching crisis point, albeit it is a “quiet crisis” to date, the GP added.
The situation is also particularly worrisome in intellectual disability (ID) units, another GP pointed out.
According to Mr Tadhg Daly, CEO of Nursing Homes Ireland (NHI), securing GP care for patients in private nursing homes is “becoming more and more challenging and problematic” and has reached “crisis point” in some parts of the country.
Mr Daly said he understood the position of GPs, who provide an excellent service in the face of increasing workloads. However, he said nursing homes were “caught in the middle”, as they had a duty of care to residents.
Mr Tadhg Daly, Nursing Homes Ireland
He said NHI is advising members experiencing difficulties to contact the HSE, which can then assign a GP to a resident. However, he said this option is a “last resort” and noted that it is rare a patient would be left without a GP.
The growing level of frailty and complexity among private nursing home residents, where the average age of residents is 82.9 years, means that patients require regular health visits, Mr Daly said.
The organisation highlighted HIQA’s National Quality Standards for Residential Care Settings for Older People in Ireland, which states that nursing home residents must receive “a high standard of service from the general practitioner with whom he/she is registered (or a suitably-qualified appointed deputy), including regular and timely consultations and an out-of-hours service that is responsive to his/her needs”.
GPs believe a new, equitable and appropriately-funded contract, which could apply to both the private and public sector, could resolve the crisis.
One GP said that “it should be about the individual and care should be the same, whether or not a patient is in a public or private nursing home”.
NHI agrees with this view. In an Oireachtas submission in 2015 regarding a new GP contract, it requested that “wherever an older person is being cared for, that they are cared for equally, whether in their own home, public nursing home or private nursing home”.
“This, however, is not always the case and once an older person moves from their own home to a nursing home, their entitlements do not necessarily follow them, as would be expected. Many of our members have expressed their concerns regarding this.”
NHI wants the GP contract to state categorically the “obligations and duties of the GP to the resident within the nursing home and with regard to the HIQA standards”.
The organisation also continues to highlight what it considers as the inequity in the cost of care between public and private nursing homes, with rates of care much higher in the public sector. Minister Harris has previously contended that public nursing homes care for more residents with complex needs, although this is contested by NHI.