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Primary care centres — a white elephant or the ‘great white hope’?

According to the Department of Health, 114 primary care centres (PCCs) are “operational” nationally.

Based on current plans, however, the figure could rise to almost 200 centres in the future, with a further 31 locations presently under construction or development, while 44 are at an early planning stage. Seven have opened so far in 2018 and a further seven will open later this year.

Commenting at the official opening of two new PCCs in Kildare and Dublin recently, Minister for Health Simon Harris remarked: “Investment in primary care is key to building a better health service. We need to ensure that more people are treated close to home, in the communities where they live. That is why Project Ireland 2040, our capital spending plan for the next 10 years, provides €810 million to construct additional primary care facilities, including community diagnostics.”

The remarks confirm Government’s intent to develop even more PCCs in the future — a plan heralded as one that will ultimately lead to improvements in the Irish health system.

But many healthcare professionals believe the current model is not the best way forward for primary care.

Some centres are in financial distress, there are reports of long waiting lists for services provided within centres, and little or no improvement in services have been reported, despite the introduction of large facilities in many towns countrywide.

‘Not functioning’

A leading primary care developer has said the PCC development model is not functioning as intended and there is little evidence of new primary care services being developed.

This is despite numerous reports recommending that services be developed in the community and primary care. Among these documents are the Sláintecare Report, published last year by the Oireachtas Committee on the Future of Healthcare and the Report on Primary Medical Care in the Community, published by the Oireachtas Committee on Health and Children in 2010.

Mr Jack Nagle, CEO of primary care consultancy firm Alpha Healthcare, has claimed that PCCs have suffered financial distress due to the economic decline of the “lost decade” and the savage FEMPI cuts of 38 per cent to general practice funding.

There has been little or no new investment in primary care and this has limited its potential and ability to boost services and supports for patients, Mr Nagle argued.

A number of GP developers who came together to establish PCCs have been hit by FEMPI cuts (ranging from 20-to-40 per cent on gross earnings), while the market decline following the crash and the lack of HSE investment are factors behind the situation, Mr Nagle said.

The GP ‘thought leaders’ and innovators who put themselves forward — investing significant amounts of time and money — have not seen the planned migration of services to the community as planned, Mr Nagle added.

 Many PCCs were built on the proviso that the HSE’s move to PCCs would lead to more integrated services within the community, but in many cases this has failed to transpire. 

Mr Nagle pointed out that the Sláintecare Report once again recommended that primary care should become the pillar of the health system.

Coupled with the other challenges facing PCCs, particularly those established by GP investors, the impact of FEMPI and the economic decline have left many centres in serious financial trouble.

Sold-off

There is now “quite a move for PCCs to be sold-off” and a trend where large investors are purchasing PCCs, Mr Nagle remarked.

Yet, the 2010 Report on Primary Medical Care in the Community strongly opposed the corporatisation of the development of a new primary care infrastructure.

It recommended that a system of incentives be provided to help the development of PCCs by professional members of the primary care teams who would be directly involved in each centre and the exclusion of large-scale corporate interests from such incentives.

PCCs have recently been sold in Kilkenny, Mallow and Mitchelstown to large healthcare groups and it is believed that more will be sold in the future.

Cork GP Dr David Molony said a large number of PCCs in Ireland are in financial difficulty because of lack of resources towards the development of primary care.

“There will be no future in healthcare without the proper development of PCCs and the new development of services,” Dr Molony said.

Mallow Primary Healthcare Centre, which opened in 2010, was recently sold to UK-based Primary Health Properties (PHP) for €20 million.

Dr Molony stressed that the centre is “very pleased” with the arrangement entered into with PHP and he emphasised that there is an excellent working relationship between the parties.

Staffing

Tramore-based GP Dr Austin Byrne practises in a separate unit within a 17,000sqft PCC that offers physiotherapy, counselling and speech and language therapy, among other services. But Dr Byrne believes the notion that “we need GPs ‘beside everything’ is flawed”.

Describing the PCCs as “white elephants”, he said the Government and HSE were putting buildings first and staffing second.

The waiting list for counselling services at the centre is nine months and, for this reason, GPs rarely make referrals to the service, Dr Byrne said.

He added that the centre has no reception or administrative support. There is a 10-month waiting list for routine physiotherapy.

“I refer 20 per cent of the caseload I should refer because of the waiting list,” Dr Byrne remarked.

“The reality is, it is a huge centre and looks great, but occupancy within the building is actually very low. Yet all the rooms are full and staff say they are short of room…There has been no discernible increase in meaningful activity. Services are ‘notionally’ available.

“Why is the HSE spending tens of millions building buildings to relocate allied care professionals — mostly part-time? GPs are crying out for services, not buildings. We are adding to capital costs and fixed overheads without increasing service capacity.”

Control

Dr Andy Jordan, NAGP Chairperson, argued that GPs were merely a “cog in the wheel” when it came to primary care team (PCT) management structures, but he argued that GPs need to take the lead.

“The HSE GP model is trying to have the GP responsible for everything but in control of nothing,” Dr Jordan claimed.

“The NAGP would have preferred if the HSE had engaged with GPs from the word go on primary care centres. We believe it would have been to everyone’s advantage had they come at it from a different way and involved all GPs in the development of PCTs and PCCs.”

Centres developed by GP investors such as at Mallow and Mitchelstown have been severely hit by falling incomes due to FEMPI, Dr Jordan said.

Meanwhile, HSE-developed PCCs and so-called public-private partnership (PPP) centres have proven divisive, he argued.

“They invited tenders but the only proviso was the developers would ensure there was one GP in the building… but there was no onus on the developer to say they would provide services. We would argue that developers should have interacted with all GPs in an area, not just one.

“The services in new PCCs are all old services. They are just moving HSE staff to another building. There are no new services, services are not fit-for-purpose and there are long waiting lists for services,” Dr Jordan said.

“We don’t think the HSE is a good provider of services. They need to move to being a purchaser of services… as by the time they have spent all the money on the infrastructure, there is no money left to provide services.”

A number of centres currently have no GPs in place, according to Dr Jordan. There have also been reports that two centres, in Carrick-on-Suir and Wexford, due to open this year, do not yet have GPs signed-up to move into them, the Medical Independent understands.

The NAGP supports the development of Primary Care Resource Centres (PCRCs), which are essentially centres of primary care with diagnostic capabilities that do not house GP services.

IMO

IMO GP Committee Chairperson Dr Pádraig McGarry questioned the need to build centres, claiming that infrastructure was already in existence in many cases. He said that the money would be better spent on manpower and enhancing services.

“Why develop PCCs when there is already capacity for what is required?” Dr McGarry remarked. 

“PCCs are buildings to provide services, but the existing infrastructure is there already. We would prefer to see additional manpower to provide services, rather than edifices.

“PCCs run the risk of removing the ownership of general practice and moving away from the independent contractor model. I believe for the long-term survival of general practice, the independent model is the ideal model, with appropriate supports, but unfortunately it has been starved to death.

“PCCs are photo opportunities for politicians in many cases — ‘look what I did in my constituency.”

Meanwhile, Wexford GP Dr William Lynch, on Twitter, described centres as “apex legacy trophies”.

This newspaper submitted a number of questions to the HSE regarding PCCs. However, the Executive failed to provide comment by press time, outlining two weeks after the questions were submitted that the response “will require some time to complete”.

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