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The rumour mill concerning HIQA’s entry to general practice has been well-oiled over recent years. The whisperings, which come in peaks and troughs, were again in evidence at the recent Medical Protection General Practice Conference in Dublin in September.
Last month, HIQA informed the Medical Independent (MI) that it had not received any communication from the Department of Health as regards commencing inspections of general practice. The Authority’s statutory remit is due to extend to general practice at some future point, although it remains unclear at present as to what form this will take.
On 7 October, Mallow GP and former HIQA board member Dr David Molony told the Annual Conference of Rural, Island and Dispensing Doctors of Ireland in Sligo that general practice needs to set its own standards and not have them imposed from outside, in advance of the extension of HIQA’s remit.
Dr Molony said general practice and primary care have nothing to fear from accredited standards. “What is a standard? I think, very importantly, it is a state of continuous improvement. It is documented but it is not a state of perfection, and everybody thinks this is something [where] you have to be at the highest possible level — it is actually a state of continuous improvement.”
Standards are normally documented, auditable and provide evidence of compliance, he told delegates.
There are agreed standards encapsulating most aspects of life from the quality of foods, cars and buildings, Dr Molony pointed out.
Dr David Molony, GP, Mallow Primary Healthcare Centre
Recalling a presentation he made a couple of years ago, it appeared there were two professional groups that did not have an agreed and applied standard — general practice and undertakers — although the latter signed-up to standards some months later. However, this did not mean that general practice was not, in fact, of a very high quality, underlined Dr Molony.
“But we have a standard in medicine which is quite different — we have the highest standard, because it is measured retrospectively — there isn’t a need for a standard until you are actually in trouble or something happens or somebody makes a complaint, and any of you who have had a complaint made to the Medical Council or anything else, you know how harrowing and how difficult that is… ”
Doctors may also face legal cases “and we all know colleagues who have been in very difficult times — and then you have a standard applied to you, then people go back and look at everything you’ve done and look at every single item you have been involved in and come back and start making decisions, but it is all retrospective….”
Better health outcomes
Dr Molony said there is huge evidence internationally about the quality of general practice, notably from Prof Barbara Starfield (a highly influential figure in the international primary care research community), who found that the effectiveness of health systems is allied with orientation towards primary care and that better health outcomes at lower costs and increased population satisfaction are achieved when primary care is appropriately supported and delivered.
“The question I would put is, why then do we get less than 4 per cent of the Irish health budget…the ministers we have talked to over the years, all of them will say one thing, there are no figures in Irish general practice, there is no evidence [of] what we do, and I see that as a failure of our organisations… but we didn’t see the need to do that and it is a failure of our own practices. We produce quality of care but we are incapable of demonstrating it. And so, we are not able to make our case in negotiations.”
Dr Molony said there are already legislative responsibilities on GPs under health and safety legislation, employment law and the Medical Practitioners Act 2007, including audit responsibilities.
He said GPs know they are providing good care with high satisfaction “but we do not have the means to demonstrate this”.
In respect of State interaction with general practice, trust is a big problem, according to Dr Molony.
“There is an element of trust here and this has led to a lot of the problems that are ongoing… general practice is a small and medium enterprise. We have been savaged over the last few years by the State, and absolutely ‘savaged’ is the word,” he told delegates in Sligo.
“There has been a deliberate under-estimation of our workload, it has been deliberate by the State and by the arms of the State, so we don’t trust the State and that is one of the problems; there is a lack of true figures on output and outcomes from general practice,” he said.
“HIQA is perceived as a new industrial organ of the State and these fears have to be dealt with. It is something to be aware of, that HIQA have a legislative responsibility and they are going to have a role in general practice and what I am saying most of all is, we need to prepare for that.”
GPs could either wait for standards to be introduced, “or I would suggest we take control of the process and introduce GP standards”.
He said he wanted general practice to be run by GPs, rather than people with nursing and science degrees with no direct experience of the specialty.
In respect of Mallow Primary Healthcare Centre, where Dr Molony is based, having recognised that regulation was coming, the centre was built in compliance with UK Technical Memorandum Standards. The centre was accredited with OHSAS 18001 2007 in respect of occupational health and safety.
In terms of clinical practice and management, Dr Molony was involved in developing the International Primary Care Standard (IPCS), which would be put in place by the practice and audited externally.
The IPCS involves a documented process of risk assessment, management and continuous improvement (for example, recording complaints and the process of response). It also includes key performance indicators (KPIs) as proof of process.
“The advantage is that primary care and GPs are able to demonstrate quality,” he said.
He said the State also gains, “because they don’t have to employ hundreds of people” embarking on site inspections in general practice.
Dr Molony said that many of the people working in regulation are nursing and science graduates, who will form their own view on what is required. He said the work of GPs was “very different” from that in hospitals, despite there being some crossover.
It was also very important to be aware of health and safety legislation, as it was a legal requirement, Dr Molony emphasised. “You must have a safety statement in place, you’ve got to show processes of getting rid of clinical waste and management… ” said the GP, who added that the Health and Safety Authority (HSA) appears to be inspecting general practice in Ireland more frequently of late.
‘Not critical of HIQA’
Speaking afterwards to MI, Dr Molony said general practice deals with people rather than disease process and disease entities, and there is compelling evidence of its clinical benefits. General practice knows what it can do well, he said. It is not good at acute coronary care, for example, but is specialised in managing long-term disease in a patient and looking at social and family parameters.
“If there is a standard in general practice, it needs to come from general practice and not be imposed. I think any imposed standard is going to give something quite different,” he told MI.
Dr Molony said he was “not critical” of HIQA and that the Authority’s National Standards for Safer Better Healthcare could be “incorporated and dealt with by GPs”.
He said “HIQA haven’t gone anywhere near general practice, but they have a legislative responsibility to go there in time”.
Dr Molony cited the example of the State’s interaction with companies when making purchases: They expect that an accreditation standard is in place.
In a similar vein, HIQA could seek details from general practices on whether there was an acceptable accreditation standard in place and then “they don’t need to employ hundreds of people”. He speculated that if practices did not comply, HIQA would then need to initiate an on-the-ground inspection.
So HIQA would not necessarily have to embark on a huge inspection process in general practice? “Yes, that’s the point I am making. If we sit back, though, they will have no choice but to do it,” Dr Molony told MI.
There had been a “very belligerent” approach in the UK through the Care Quality Commission (CQC) inspection process, said Dr Molony, adding that “unless we do something, that is what will happen here”.