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Call to ‘act now’ to remodel ‘upside-down’ health service
The Government and HSE need to “act now” to make a “decisive” shift towards primary care, the CEO of the NAGP and Chairman of the Primary Care Partnership Committee has said.
Speaking on the opening morning of the Primary Care Partnership Conference in Croke Park, Mr Chris Goodey said Ireland has an “upside-down health service”.
NAGP CEO Mr Chris Goodey
“We have a system that encourages attendance in expensive hospitals that does nothing to encourage the management and treatment of patients in primary care,” said Mr Goodey.
“We need courage and conviction and we need our politicians and our leaders to make difficult and sometimes unpopular policy decisions.
“Research shows that investment in GP-led primary care, where patients can access more care in the community, results in better patient satisfaction and saves the Government money. Why, then, are we still waiting for this decisive shift to primary care?
“At this conference, I call on the Government and the HSE to act now, do the right thing for the patients of Ireland and make that decisive shift to primary care.”
Speaking later that day, Minister for Health Simon Harris seemed to echo many of Mr Goodey’s sentiments.
“I’m sure many of you have heard me say it before but I’ll say it again, 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,” Minister Harris told conference delegates.
“I want patients to have access to safe and clinically-effective treatments early, as close to their home as possible and at the lowest level of complexity. I don’t want to just talk about making this decisive shift; I want to make it a reality.”
Minister Harris said he believed that the final report from the Oireachtas Committee on the Future of Healthcare, due this month, will indicate a renewed focus on primary care.
The conference also heard from Ms Kathleen Canning, National Chairperson of the Irish Practice Nurses Association (IPNA), who said that more practice nurses are needed in Ireland to boost primary care services.
“There are about 2,000 practice nurses in Ireland. I think the ICGP have said they would like to see 5,000,” she told the conference.
During his speech, Minister Harris said he wants “to make sure that our practice nurses and other healthcare professionals have an opportunity to feed into the development of this [primary care].”
Over 350 health and social care professionals were registered to attend the Primary Care Partnership Conference in Croke Park to hear 32 national and international thought-leaders provide evidence for change from other health systems in the UK, Germany, Australia, the US and Canada.
The theme of the conference was ‘Defining Primary Care in the 21st Century’.
GPs need to ‘step up’ for primary care progress
GPs will need to “step up” when it comes to performance if primary care is to become the leading part of the health service, a US academic told the recent Primary Care Partnership Conference in Croke Park.
Dr Kevin Grumbach, Chair of Family and Community Medicine in the USCF School of Medicine (San Francisco), US, told the conference that Ireland, like the US, has a problem “when people have no assurance to access across all income groups”.
“There is a combination of lack of universal coverage and lack of real investment and prioritisation of primary care,” warned Dr Grumbach about the Irish system.
“It requires a contract, a new partnership between people working in general practice and Government. From Government, you need this transitional funding. But it’s not credible to ask for more money from Government unless there is a willingness to be accountable for performance in response to these resources.
“This is the way we have negotiated in the United States. Yes, we need more investment, but then we need to step up and be accountable for better access and quality performance and better patient experience.”
Dr Grumbach added that “no government wants to pay more and get the same product”.
“So that’s my sense of the question for all our nations. Are the people in the general practice, primary care community, ready to step up and in return for greater investment, to deliver a more highly-performing model of care?”
Dr Grumbach was just one of a number of foreign speakers at the conference.
Prof Elizabeth Dean, Professor at the Department of Physical Therapy at the University of British Columbia, Canada, said that GPs have a vital role to play in disseminating the message of healthy living among patients.
Prof Elizabeth Dean, University of British columbia, Canada
“Most of you are going to touch more than 250,000 lives with individuals and families,” said Prof Dean. “That’s a lot of teaching moments that are probably being under-exploited.
“It’s within your grasp. I think by rethinking and refocusing on these priorities and getting this health promotion piece right, we can ensure that our future generations of health professionals are well equipped to deal with lifestyle-related conditions.”
HSE DG calls for end of professional and sectoral rivalry
Inter-professional and inter-sectoral rivalry have been a significant problem in the health service, the HSE Director General told the recent Primary Care Partnership Conference in Croke Park.
Mr Tony O’Brien said the upcoming report from the Oireachtas Committee on the Future of Healthcare would offer a chance for unity in the health sector.
Looking back over his period working in the Irish health service to date, Mr O’Brien said that “the one pre-eminent thing I have seen is that professional rivalry, regional rivalry, sectoral rivalry have always trumped consensus.
HSE Director General Mr Tony O’Brien
“In my view, that is one of the most significant reasons why we’ve not achieved consensus, why there is divide-and-conquer, why there has been flip-flopping politics.
“We have never reached a place in which everyone knows what is reasonable to expect from our health system, where everyone is prepared to make the same amount of fuss about the shortcomings in our health system, as we are about, say, water charges.”
In light-hearted comments in his speech, Mr O’Brien said that he is “now two-thirds of my way through my sentence as Director General of the health service. Whether I will get time off for good behaviour remains to be seen”.
However, Mr O’Brien was more serious when talking about the style of leadership he believes he has brought to his role.
“In that almost four years I have been in the role, I have pioneered a thing that I call ‘speaking truth to power’,” said Mr O’Brien.
“Originally, it started off when it became apparent to me that the health system is quite hierarchical. People were often telling me what they thought I wanted to hear, rather than what I actually needed to hear.
“Also, I have consistently tried to take the same approach to the political system, telling it what it needs to hear, rather than what it wants to hear — not always making me terribly popular, it has to be said.”
Harris reaffirms commitment to ‘fit-for-purpose’ GP contract
General practice needs a “fit-for-purpose” contract, the Minister for Health Simon Harris told the Primary Care Partnership Conference in Croke Park.
“We need a GP contract fit-for-purpose,” Minister Harris told the conference, departing from the text of his distributed script.
“Working off a 44-year-old contract that has been changed and tweaked with bells and whistles hung on it over the last number of years is not the way to show that you are attaching priority to general practice.”
Minister Harris said he will be speaking to the NAGP in the coming weeks about the contract talks. The Association, which was a key player in organising the conference, has been critical that it is not receiving equal treatment with the IMO in the negotiations.
“As you know, we are at the early stages of negotiation of a new contract for GPs. I am committed to ensuring that patients throughout the country continue to have access to GP services, and that general practice is sustainable in all areas into the future. It is imperative general practice remains an attractive career option for newly-qualified GPs,” said Minister Harris.
“As such, the aim is to develop a new, modern GP services contract which will incorporate a range of standard and enhanced services to be delivered. It is also important to continue the development of GP capacity in order to ensure that the future manpower needs of general practice can be met.”
Minister urges healthcare professionals to rally around Alcohol Bill
All healthcare professionals have been urged to actively rally around the Public Health (Alcohol) Bill.
Minister for Health Simon Harris made the call at the recent Primary Care Partnership Conference in Croke Park.
Departing from his written speech, Minister Harris commented: “Much more is needed when it comes to discouraging harmful levels of alcohol consumption. Alcohol is fast becoming ‘the new tobacco’ in relation to our healthcare system.
“I would genuinely ask all healthcare professionals here to work with us in trying to bring about this radical policy shift in terms of alcohol.”
As reported in the Medical Independent (MI) earlier this year, the delay in the passage of the Bill has been criticised by leading doctors. Concerns have also been raised over the heavy lobbying conducted by the alcohol industry, which Minister Harris also hinted at in his remarks.
“If we can get this Bill passed, it will be the first time in this country to get a public health bill that relates to alcohol [passed],” said Minister Harris.
“We have done it in relation to other areas; we have never done it in relation to alcohol and we have a problem with alcohol in this country. We have many vested interests working very hard to try and convince us that we don’t have a problem, or we don’t have the problem we think we have.
“This is a ‘David and Goliath’ battle and I really do need the help of healthcare professionals to make this a reality.”
Addressing the contents of the Bill, Minister Harris said that “there are a suite of measures contained in the Public Health (Alcohol) Bill which I consider to be a proportionate response to addressing the harms caused by the misuse of alcohol and to bring about a cultural shift in our attitude to alcohol”.
Physician associates are ‘part of the solution’, according to London GP
Suspicion about the role of physician associates (PAs) in UK general practice has diminished, as many GPs see the practical value in this adjunct position, according to a prominent London GP.
PAs have been operating in the UK for several years but are a more recent development in Ireland, where a small-scale PA pilot is ongoing in the surgical directorate at Beaumont Hospital, Dublin.
Dr Nav Chana, Chairman of the National Association of Primary Care, UK, who spoke at the Primary Care Partnership Conference in Dublin, told the Medical Independent (MI) that doctors were initially concerned that recruitment of PAs was a means of replacing them “on the cheap”.
“I think initially, like all things new, there is a suspicion. I think the biggest worry was that this was ‘instead of’… But over the years, what has been clear to me is it has been more about ‘as well as’, not ‘instead of’ and it is part of the solution that you have, where you can’t recruit, the team’s workload is high… They act as part of the skill-mix solution.”
He said that with the publicity around NHS England’s investment in primary care, the position of PAs was a “clearly signalled role”. He said people are “beginning to recognise value and work within that, rather than be suspicious about it”.
Dr Nav Chana, Chairman, National Association of Primary Care, UK
Dr Chana’s surgery in London, which has had PAs since 2008, as well a number of different roles, is also a training practice for PA students from a nearby teaching hospital.
He said triage and training of receptionists are crucial in terms of integrating the role.
“It is really important that when people phone in and say, ‘I want to see a doctor’, that the response is ‘that is fine, no problem, but it may be a while before the doctor can phone you back; we have got a physician associate who may be able to speak to you straight away’. And once you have explained that, it helps, as long as you make it clear. People often worry ‘is a doctor available or around to deal with the query if needed?’ That [message] reassures people. Physician associates are not autonomous, they are meant to work as part of the supervised medical care system… depending on their competence, they are meant to seek approval and advice before they make independent decisions about things.”
On whether supervising PAs generated a heavy workload, Dr Chana said it depended on the competencies of the individual PA. “Obviously, if someone starts a new role, then you may want to go through things a bit more carefully with them. But as they become more adapted, become more confident and take more responsibility for things, you are still there — so they need to know when to come and see you, when they need advice — but you may not need to be there, you might not need to check every single query. They can manage quite a lot of stuff themselves, but it is really important that they know when they are out of their depth, they need to go and see or speak to a doctor to get some advice.”
MI asked Dr Chana how it was ensured that a highly-complex case that presents to the practice is seen by the GP.
Dr Chana said that if, for example, an elderly person came to the practice feeling unwell, they would require a very thorough work-up, including patient history, blood pressure, temperature, physical exam, etc. This would be undertaken by the PA to ensure this information was ready for the GP to assess.
“The physician associate comes and sees the GP and says ‘look, with Mrs X, here is what we found, here are the measurements, this is what I think is going on — what do you reckon?’ We have a chat, make a decision and that is sorted. So while the physician associate has been doing all of that stuff, I am seeing other patients, but we are still overseeing what is going on. It helps to get that person properly sorted out. Because often, that presentation in a general practice setting might be really quite disruptive for the GP because they now take 30 or 40 minutes to try and sort that out, whereas now you have someone on hand to take care of that while you are doing something else — but you are still overseeing the decisions that are being made, what is being prescribed, whether they need to be admitted or not.”
Currently, the PA profession in the UK is in the process of seeking regulation. Dr Chana said this was important from the perspective of affording PAs prescribing authority.
He believed PAs acquiring prescribing powers would be a positive development.
“Yes, because obviously if you can make these guys independent prescribers, that helps with workload. Physician associates can make prescribing decisions, they understand pharmacology and understand which drugs interact with others and things like that, but [currently] they cannot physically sign a prescription.”
Earlier at the conference, Dr Chana had outlined the development of the ‘primary care home’ model, which is endorsed by NHS England. This model places a heavy emphasis on multidisciplinary teams in primary care, thereby releasing more time for GPs. To date, the model has 92 sites across England. According to literature from the National Association of Primary Care, which was highly involved in developing the model, benefits recorded at pilot sites have included 67 per cent of staff surveyed feeling that the model had improved their job satisfaction, 82 per cent of staff feeling that the primary care home had improved patient experience, and £27,000 of savings each year enabled by providing extended primary care access in Thanet. In respect of population health, there was a 13 per cent increase in flu vaccinations for patients with COPD registered with Beacon Medical Group.
The primary care home is developed, implemented and led by providers, while being supported by commissioners. According to Dr Chana, the model fosters collaboration throughout the system.
Its key features include provision of care to a defined, registered population of between 30,000 and 50,000; aligned clinical financial drivers through a unified, capitated budget with appropriate shared risks and rewards; an integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care; and a combined focus on personalisation of care, with improvements in population health outcomes.
DoH has ‘lost control’ of health service governance — Dr Michael Harty
The Government has devolved the running of the health service to the HSE, while the Department of Health “has lost control in relation to governance”, Independent TD Dr Michael Harty told the Primary Care Partnership Conference.
In a panel discussion following his talk on health service reform, Dr Harty said it had become clear that there is a “greyness” as to where responsibility rested. The Independent TD, who chairs the Oireachtas Committee on Health and is a member of the Oireachtas Committee on the Future of Healthcare, commented: “In relation to governance, there is very little governance between the HSE and the Department and the Minister. It has become obvious in our committees that there is a greyness in where the responsibilities lie and the Government has devolved the running of the health service to the HSE, and I think the Department has lost control in relation to governance.”
He continued: “I think [HSE Director General] Tony O’Brien, in fairness to him, realises there is a huge governance deficit. So there has to be a very strong governance underpinned by legislation because you are not going to get governance on a voluntary basis; there has to be a structure, there has to be accountability and answerability.”
Meanwhile, the Co Clare TD also acknowledged the “apprehension” felt in general practice about its possible evolution. The final report of the Oireachtas Committee on the Future of Healthcare, which is due to be completed this month, will emphasise the need to move towards a primary care-centred health system. Dr Harty said one of the responses required will be for GPs to orientate more towards management of care and devolve some aspects to other health professionals.
“GPs should probably be managers of care — yes, they should supply care but they should also manage care, so we don’t have to solve every problem. But we do need to be the signpost to direct people to the most appropriate person to solve their problem, be it podiatry, dietary or physiotherapy… I don’t think we see our ourselves as managers; I think we see ourselves as people who take on all the problems and try to solve them ourselves and we have to change that mindset as well.”
Dr Harty said the final report of the Oireachtas Committee will “challenge” many current practices. “And that will be painful for people — it may be painful for general practice, it may be painful for hospital consultants. We need new contracts and we need to work in a different way. It is going to be a game-changing report. But implementation, the last chapter, is the key.”
Also speaking during the panel discussion, Kilkenny GP Dr Ronan Fawsitt said he believed GPs need to get behind the Oireachtas Committee.
“We won’t get everything we want; that is okay, but we will have a journey and integrated care is a journey — a patient journey is the most important one of all.”
Dr Fawsitt said a paradigm shift is required towards team-based care in the community.
“We desperately need political cover and a transitional funding model to actually make the Oireachtas Committee system work. But GPs will be central, not centric, to a team-based process… This is it, lads — it won’t be perfect, but it is probably the best way forward.”