As many as one in five newly trained GPs are leaving the system shortly upon the completion of their training, a contributing factor to the growing public waiting list, which is in excess of 650,000 patients.
Many blame the current unsatisfactory primary care system for this emigration, which is placing marginalised practices,such as those in rural areas, under increasing pressure and compromising the continuity of care for which Irish GPs are known. Planning behind primary care centres has been 16 years in the making; where do GPs want to see the “fastest growing healthcare systems segment of developed countries” improve?
Sixteen years since the publication of the ‘Primary Care Strategy’, The National Association of General Practitioners (NAGP) has criticised the “significant deficits” that remain in the GP system in terms of infrastructure, staff, resources and connections, in addition to “onerously long” waiting times for diagnostics.
In their report, published in September, ‘Defining Primary Care in the 21st Century’, the NAGP cautioned that the current Primary Care Centre (PCC) structure serves to foster a culture of competition between general practices.
The IMO made a similar statement in their submission to the Oireachtas Health Committee in February 2017, claiming that corporate models of primary care would not benefit general practice in the long-term, as it is “profit-focused not patient-focused”, and could potentially disrupt continuity of care and increase supplier induced demand.
To tackle issues with the current PCC model, the NAGP has backed the re-designation of these centres as “primary care resource centres” (PCRCs), meaning that they could serve as diagnostic and service hubs, supporting patient-focused care with total engagement from local GPs and a point where public and private models could intersect.
“The idea is that PCRCs would be ‘neutral territory’; a properly resourced PCRC could bring together GPs and all primary care health professionals in a community independently of location, and allow the full and proper integration of all services under the primary care umbrella”.
The report stated: “This would create an environment where primary care teams can deliver for patients and would bring all GPs and health professionals into the same process, regardless of where their practice was physically situated. It would assist primary care to reach its potential for more care in the community and achieve greater self-sufficiency, with less reliance on hospitals”.
The report also alluded to negative GP opinions regarding PCT (Primary Care Team) meetings, as many have claimed that they are ‘a waste of valuable time’, irrelevant to them, and poorly organised.
According to research conducted by the ICGP (O’Riordan 2015), less than 16 per cent reported favourably on their experience with PCTs.
Dr Jonathon Jacob, Primecare & TMB, Carlow, is one such GP, who told IMN that he fails to see the functionality of these meetings.
He stated: “They don’t have any functionality, they don’t actually achieve anything; in one meeting there might be five GPs, in addition to the public health nurses involved with that cohort of GP patients, and Occupational Therapists and Social Workers. Everyone’s cases are discussed, one after the other.
“I agree that there should be some sort of tangibility between general practice and paramedics but this is a very inefficient way of doing it. It’s not as if we’re time rich and I’m sure the others sitting at these meetings aren’t either”.
In 2016, the Irish Medical Organisation (IMO) made written and oral submissions to the Indecon Report on Primary Care Facilities, calling for consultation with existing GPs in an area before developing any Primary Care Facilities.
This call was echoed by Dr Jacob, who expressed his disappointment that more GP input wasn’t taken into account before the process of setting up these centres had begun. He emphasised how continuity of care is the strength of general practice and how that should be a central factor in any primary care facility.
“What they needed to do was to get rid of the geography of the health boards but they haven’t. I live in Carlow, I’ve got three health boards to serve, so I’ve got three of everything and possibly more; in Carlow town I probably have four or five public health nurses who I have dealings with; it’s nonsense.
“The GP cohort is the only one where people are involved in choosing, you don’t choose who your public service dentist is, you just go to the one you’re given and it’s the same for your public health nurse.
“At the moment it’s on a geographical basis but people choose their GPs and there’s a certain stability about that, which is why that has to be the starting point.
“They need to look at where people are going for their GP services and then fit the other things around it. That’s not intended to sound egotistical; it’s simply the only logical way that I can see because it’s the only area where patients choose.
“If they had developed real estate collocated premises solutions for people so that you had a certain number of GPs and you matched paramedical services to that cohort, then I think that would be good.
“Even without the collocation, if they had arrange the cohorts properly so that GPs knew who their speech therapist, or OT, or dentist was, then that would make a lot of sense”.
He concluded: “At the moment it strikes me that it’s all these wheels turning without any real connection to each other. I find it something of a white elephant as it stands, to be honest”.
This week, two representatives of the Irish College of General Practitioners (ICGP), Dr Brendan O’Shea, Director of the Post Graduate Research Centre, and Dr Mark Murphy, Chair of Communications, attended the Joint Oireachtas Committee on Health in relation to primary care expansion’, as recommended in the Sláintecare Report.
Once again, the advice issued from the report was for an “adequately supported” independent contractor model over a corporate one. The report stated that an independent model would be “more likely to deliver stability and continuity, which are important for both the practitioners and the people who rely on the service”.
The report criticised how the HSE has; “utilised the development of PCCs to enable the more rapid development of corporate primary care chains in selected locations in a manner which has unfortunately compromised the continuity and quality of care, and shifted the balance of autonomy and franchise of GPs and their patients, living in a particular community, away from that community, and towards vested external business interests”.
While recognising the shortcomings of the corporatisation of primary care, the ICGP stated that it would work with relevant stakeholders to manage risk, and continue to promote the model preferred by GPs; the “independence of working in a service in which they are effective stakeholders, and in which they can adapt and develop in accordance with the needs of the local community they serve, and with their own professional needs, as community based doctors”.
The immediate reversal of cuts introduced under the Financial Emergency Measures in the Public Interest (FEMPI) legislation and the replacement of the present GMS contract with one that addresses the needs of people who attend GPs and their practice teams for ongoing medical care were recommended as vital stepping stones in the journey towards a better functioning primary care system.
The college also expressed full commitment in the expansion of training and educational capacity for general practice, to assist in facilitating an increase from 3,700 GPs and 1,700 practice nurses in 2017, towards a minimum of 5,000 of each in the coming decade, capable of addressing the needs of an ageing population of 5 million citizens.
According to the ICGP, adequate capacity in GP-led primary care will be crucial to keeping Irish healthcare afloat. Should this fail to happen; the report predicts that the remainder of primary care, the secondary care sector, and the broader health system will never function safely or efficiently.