The introduction of universal primary care will remove the need for those currently without a medical card to pay fees directly to a doctor, writes DR MUIRIS HOUSTON
THE MINISTERS’ feet are under the table. The programme for government, while a mixture of both parties’ health plans, has a Fine Gael tinge. But the appointment of Labour’s Roisín Shortall as Minister of State for Primary Care is the strongest indication of the priorities we can expect to see in healthcare in the coming months and years.
From the patient’s perspective, the introduction of universal primary care will remove the need for those currently without a medical card to pay fees directly to a doctor.
It is expected that this fundamental change will be phased in, with those who currently receive free drugs under the long-term illness scheme given free GP care first; in the second year of the plan, free care will be extended to those people covered by the high-tech drugs scheme, with some form of subsidised care introduced next before the eventual implementation of free primary healthcare for all.
For some doctors, the changes will be enormous. GPs will be paid on an annual capitation basis – the method now used to pay doctors for medical card patients.
For those practices with a high percentage of GMS patients, the change will be a moderate one. But for those with a high turnover of private patients and who have developed a per-item pricing system over the years, moving to capitation payments could prove seismic as it fundamentally alters the small business model that is their modus operandi.
All GPs will work in primary care teams and it will become compulsory for everyone to register with one of these teams. This move will bring to an end the practice among a minority of private patients who “doctor shop” with different complaints. And it will bring much-needed clarity to the overall management of the health service and its constituent costs.
Universal primary care will need additional manpower for it to work. We will need to train more GPs and practice nurses.
Recruitment embargoes notwithstanding, a way will have to be found to employ some of the hundreds of young occupational and speech therapists who we train here but who have had to emigrate to find work.
The new health plan will succeed or fail depending on how well it looks after people with multiple chronic illnesses.
This is the reality of modern healthcare: with people living longer and successful treatment of hitherto fatal illnesses, most of us aged over 65 will have two or more health conditions. These include heart disease, diabetes, high blood pressure, arthritis, kidney disease, chronic respiratory disease and dementia.
Until now, the focus of treatment guidelines and the organisation of patient care pathways has been disease specific. As a result, people with multiple chronic diseases often receive disjointed care. At its worst, this care can be conflicting and may even result in avoidable complications and adverse reactions to treatment.
Under a successful primary care model, the team will have the resources to support patients who undertake non-drug approaches to their chronic diseases.
Reducing salt intake, eating enough fruit and vegetables and exercising regularly may reduce the need for medication. And a good team approach will help to forestall a situation where the treatment of one chronic condition may actually be harmful for another disease the patient is also trying to deal with.
Rather than a specialist giving their best advice for one condition and a colleague doing likewise for another, a goalkeeping approach based in primary care has a better chance of making the compromises necessary for the practical care of multiple diseases.
It may come down to asking the individual what their priorities are: symptom relief, to be able to function independently or to live as long as possible?
Fine Gael’s health manifesto, much of which appears in the programme for government, was based on a Dutch model of care. Since January 1st, 2006, the Netherlands has had a single statutory health insurance scheme for all its residents.
It has three main features: long-term nursing care; what it calls “care with a view to a cure”; and a facility for individuals to take out supplementary insurance.
A key element is that private companies provide most healthcare but with strict regulation provided by government.
The Dutch Health Insurance Act provides the same level of cover that existed under the previous fragmented system: a combination of health fund insurance, social health insurance for employees, people receiving state benefits and people aged 65 and older.
The system is funded through a combination of a nominal premium paid by everyone over 18, income-related premiums and public funds.
The success or otherwise of the new administration’s plans will be decided on how it manages the expansion of primary care centres.
These must be solidly functioning units, clearly identifiable to local communities and not “virtual” teams created to massage numbers as has happened in the past.
A fatal flaw in the HSE’s way of doing things has been its failure to build up primary care teams before attempting to decant patients from the hospital system. Unlike the Netherlands, we do not have fully functioning patient-centred primary care teams.
To attempt this degree of reform will require an element of “transformation” funding – will this be forthcoming? There is an enormous challenge in managing the detail of this change and some serious “heavy lifting” lies ahead.
Even with a phased approach, these welcome changes may take longer to implement than either the Minister or the public would like.