HSE says reforms to key areas of primary care system are needed

The Health Service Executive has said there are more than a dozen areas within the country’s primary care services that require further development and reform. It said that greater clarity was needed in relation to access to services and eligibility for access, for example, to aids and appliances which were at present based on qualification criteria for medical cards in many parts of the country.

The HSE also said that “inconsistent coverage” by GP out-of-hours services represented “a significant deficit that can lead to inappropriate attendance at hospital emergency departments”. A “lack of standardised GP access to diagnostics” was also identified, resulting inappropriate presentation to hospital out-patient departments and emergency departments.

“Improved access to diagnostic tests remains a key priority for enhanced primary care.”

The dozen or so areas within primary care that required further reform and development were set out by the HSE in a submission to the new Oireachtas committee examining the future of healthcare in Ireland.

Access

The HSE said that the issue of access to services and aids and appliances continued to cause difficulties and inconsistency in relation to eligibility.

“The access criteria used in many community health organisations is based on the provision of services to medical card holders who have eligibility under the Health Act 1970. Inconsistency in relation to access can lead to inappropriate acute service attendance.”

“There is a need to develop a clear set of statutory provisions to ensure ease of access and transparency and to bring the system up to date with developments in service delivery and technology since the Health Act 1970. The public health nurse is a key member of the primary care team and provides many services not otherwise available in a private capacity. In many cases, access to the public health nursing service is provided to medical card holders only. Medical card eligibility is used as a mechanism for managing this finite resource.

“An applicant for a medical card may be significantly over the financial threshold, but due to their diagnosis, access to one or more community services may be essential. In order to avoid the risk of a patient being unable to access vital services, discretionary eligibility may be recommended to ensure continuity of service. Due to a lack of a private alternative to the public health nurse and their pivotal role, provision of public health nursing services and necessary aids and appliances should be standardised and based on need rather than medical card eligibility.”

The submission notes that GPs were core members of primary care teams, but “there can be difficulties experienced in integration between the team and the GPs”.

The HSE also said the existing GMS contract impacted on the roll-out of chronic disease programmes and enhanced models of care in the primary care setting. It said a process of engagement with GP representatives and other stakeholders would be “a key element in the wider contracts review which encompasses the GMS and all other publicly-funded health sector contracts involving GPs”.

In its submission the HSE maintained that “a significant deficit that can lead to inappropriate attendance at emergency departments is inconsistent coverage of GP out of hours services”.

"Deficits currently exist in the North East, the West and Dublin North Wicklow areas of the country. The number of contacts to GP out of hours services in 2015 was 980,917. From January to June 2016 there were 558,633 contacts, an increase of 12 per cent on the same period last year.

Needs of patients

Meanwhile the Department of Health has told the new Oireachtas committee that it wants to see greater focus on the needs of patients with chronic diseases as part of a planned new contract with general practitioners.

In its submission to the committee on the future of the health service, it set out greater clarity on its aims for the revised GP contract. It said that a shift from hospital-based interventions for chronic disease towards primary care and population-based interventions could deliver a reduction in chronic disease and improve the health of the population.

“General practice is well placed and therefore has a central role to play regarding the prevention of chronic disease and supporting self-care and self-management for patients.” Its submission noted that “the new universal GP service for children under six years of age includes weight management and asthma prevention as a key element in the overall care provided. The general practitioner service also included a cycle of care for diabetes in older individuals to manage the condition and prevent further complications.”

The Department of Health said the further development of the publicly-funded general practitioner service to include additional chronic diseases was “ under active consideration”. It said the work underway in its development and the new GP contract would provide for GPs working as part of multidisciplinary teams providing integrated care with a focus on the needs of patients with chronic diseases.

“The additional chronic diseases planned in the contract include cardiovascular disease (heart failure and rhythm disorders), diabetes, COPD (respiratory disease) and asthma. The care will involve prevention, early detection as well as integrated management. Such integration is a key part of the overall care. The scheduled management will include diagnostic tests, clinical assessment of the severity of the condition and clinical management in primary care in accordance with clinical protocols. The proposed investigations and treatments are based on models of care developed by the [HSE’s] clinical programmes. The requirement for specialist care where required is included in the overall model of care.”