Was the primary care strategy of 2001 overly ambitious in its original targets, writes EITHNE DONNELLAN
COUNTRIES WITH more comprehensive primary care systems tend to have lower healthcare costs, lower mortality rates, longer life expectancy and greater satisfaction with their healthcare system.
That’s according to a new report from the Oireachtas health committee and it’s presumably something any health minister and any patient would wish for.
It is, in fact, what was envisaged for Ireland back in 2001 when, amid much fanfare, a national primary care strategy was launched by the then health minister Micheál Martin.
It promised at least 600 primary care teams would be established here by 2011. The teams would include health professionals such as family doctors, midwives, social workers, public health nurses and physiotherapists providing care to patients in the community from under one roof. These teams, it said, would effectively offer patients a “one-stop-shop” to cater for up to 95 per cent of their health needs without them having to set foot in a hospital.
However, the Oireachtas health committee, which in its report published last week reviewed the progress made to date in implementing the strategy, found while some progress had been made, it’s significantly less than would have been expected at this stage.
It noted that 222 primary care teams had been established by the end of November 2009 and of these just 112 were “at advanced functioning stage” which it defines as holding clinical team meetings to discuss and plan integrated care for individual clients.
A breakdown of the 222 teams provided to the Oireachtas committee also showed 31 were in place “without GPs”.
In addition, the HSE gave the committee a list of 32 primary care centres to house its primary care teams which it hopes to see opening this year but the report doesn’t make clear how many primary care centres have been provided to date.
The reality is very few have and the Oireachtas committee now says incentives, such as tax breaks, should be provided by the Government to kick-start this process, as primary care teams “need to be in one single location to be most effective”.
The Minister for Health, Mary Harney, says she believes “if we don’t have some of the reliefs suggested here, we will not see the acceleration of the facilities that everybody wants to see”.
So was the primary care strategy overly ambitious in its original targets, given the progress made to date in implementing it?
Dr Tom O’Callaghan from one of the few fully functioning primary care teams in a purpose-built centre in the State – in Mitchelstown, Co Cork – says there’s no harm in being ambitious. But he believes where the strategy fell down was in bureaucracy and the “legal minefield of public procurement”.
It took 24 months for the HSE for example to sign an agreement with his primary care centre to lease space in it to provide public health services for local people. But now that the agreement has been signed, local women can avail of antenatal care at the primary care centre rather than having to travel 33 miles to Cork University Hospital (CUH) for appointments. An obstetrician from CUH visits once a week and pregnant women only have to visit the hospital for their delivery.
The purpose-built centre opened in 2008 having been established by six GPs at a cost of €10 million. It provides a wide range of services including training for a number of final-year medical students from CUH. O’Callaghan says it’s working very well.
“I think there is a huge appetite on the ground among GPs to come together and work together in a group setting . . . but there has been very little concrete support centrally from Government to make it happen,” he adds.
Furthermore, he claims the HSE is just ticking boxes when saying there are primary care teams all over the place. They are in fact “virtual” primary care teams, with some meeting only once a month, he says.
“It’s semantics really. You have people at senior management level in the HSE believing they have met their obligation if these meetings are happening but that is not real change,” he adds.
Dr Mel Bates, of the Irish College of General Practitioners (ICGP) and a Dublin-based GP, agrees. “The number of primary care teams supposedly in existence is extremely impressive and I don’t see any evidence of that on the ground,” he says.
He says the jury is also out among some of his colleagues as to whether some of the “virtual” primary care teams which the HSE says have been established are mere talking shops. “The problem is that there are no buildings to go with the primary care strategy. The lack of a unifying building means the primary care team is a virtual team and it’s very hard to develop relationships with your fellow health professionals in that sort of situation,” he says.
“Where the strategy has worked, there has been a building,” he adds.
Given a lack of funding for the primary care strategy, the HSE called in 2007 and 2008 for expressions of interest from the private sector to build primary care centres from which it would lease accommodation. It has now issued “letters of intent” to lease accommodation at 95 locations.
But as one private company Touchstone, which announced plans to develop 60 primary care centres across the State in 2004, found out, it’s not as easy as it might seem. Fergus Hoban, its managing director, admitted yesterday only two have been established to date and he will be lucky to develop another six during his career. His first one opened in Mulhuddart, Dublin, in 2005 and another has just opened at Blackrock Hall in Mahon, Cork.
The problem, he says, was booming property prices over recent years meant the company couldn’t secure sites or buildings at any sort of affordable price. The HSE, he says, is to place three primary care teams in the €18 million Mahon centre this summer.
“It’s one of the hardest jobs in business to make a primary care centre function,” he adds. But he warns against further cuts to fees of practitioners in the primary care setting if their businesses are to be sustainable.
Meanwhile, the HSE insists it is on target to have about 530 primary care teams in operation by the end of 2011 and it says it now believes 542 will be sufficient for the whole country.
In addition, it says, GP shortages – which the Oireachtas committee recommended should be addressed immediately – are being taken seriously. The HSE says it’s in the process of increasing postgraduate training in general practice, from the current figure of 120 a year “to a potential 160 posts commencing in July 2010” and it’s to be done within existing resources and in consultation with the ICGP.
But improving primary care services in line with what was envisaged in the national health strategy cannot be done from within existing resources. If the HSE expects to be able to save money by continuing to cut acute hospital bed numbers, hospital admissions and the length of stay of patients in hospital, it must invest more in primary care, particularly in diagnostics at local level.
600
primary care teams were to be established by 2011
222
primary care teams had been established by the end of November 2009
112
are 'at advanced functioning stage'