The cuts of 7.5 per cent to GPs are indefensible based on the population health evidence which now presents itself. In the wake of a massive decline in hospital beds, an inadequate number of hospital specialists and growing waiting lists, and a dramatic rise in mental illness and suicide, GPs are holding the Irish health system together.
The cuts are even more incredible, given the Government’s plans for integrated health and social care in the community, geared towards keeping people out of hospital and residential care, in the context of de-institutionalisation and population ageing, now well progressed.
Ireland has 141 specialist medical practitioners per 100,000 of the population, the second lowest of 26 countries (mainly EU) surveyed by Eurostat. Only Turkey is lower, with 121 per 100,000. Germany has 216; Spain, 240; and the UK, 192.
In addition, Ireland has the fourth lowest number of hospital beds per 100,000 of 28 Eurostat surveyed countries at 313.9, with an average of 538 beds across the 28. Germany has 825; France, 642; and Portugal, 347 (all figures for 2010, the most recent available). As recently as 2004, Ireland had 564 hospital beds per 100,000.
The population of the Irish State, according to the most recent census (2011), rose by 348,404 from 2006 to 2011, alongside a dramatic fall in hospital beds by almost half between 2004 and 2010.
One of the few saving graces for Ireland in this appalling demise has been the number and quality of its GPs. Ireland had the highest number of GPs per 100,000 at 279 in the 2010 Eurostat survey, but even this had fallen significantly from 298 in 2006.
Hospital waiting lists
As of July 1st this year, on the back of a 96 per cent rise in hospital waiting lists, the total on such lists reached 48,279, with 3,062 people waiting between nine and 12 months and 653 over a year.
GPs have to deal in a primary care environment with these patients, often trying to keep many alive, while they wait for hospital procedures. A further challenge to GPs is mental illness which has reached alarming proportions, with over 30 per cent now in need of a mental health intervention.
But the Government has failed to implement Vision for Change (2006), its own policy aimed at providing comprehensive mental health services for the first time in the history of the State.
It is virtually impossible to get cognitive behavioural therapy on the public health system, which tens of thousands need as the most proven intervention. GPs are again left trying to manage the situation and the various categories of patients including those with serious illnesses such as bipolar disorder and schizophrenia, but also those who are addicted to alcohol and drugs.
Primary care level
Over 90 per cent of all healthcare is delivered at the primary care level by GPs, nurses and associated health practitioners. In 2011 we had 532,000 people over 65 years of age. In 2031, we will have over 1 million. There will also be an increase of 370,000 people aged 45-64, according to census 2011 population projections.
In response, the Government policy has been to move the health system towards more primary and community care to reduce the growing pressure on hospitals. The vehicle for this has been the promotion of “integrated care”.
The HSE and Department of Health have been working on developing integrated health and social care since the department's primary care strategy of 2001 and various HSE programmes, including the HSE integrated service document (2008) and subsequent national and regional service plans.
The Vision for Change policy is also about integrating health and social care in the community for mental health service users. Likewise, the HSE has been planning to discharge people with disabilities from residential settings into the community as per its Time to Move on from Congregated Settings report of 2011.
It has arrived at a four-tier integrated services model which spans primary care, social care, secondary hospital and tertiary hospital care. The lynchpin in all these policies is the role of GPs. They will be key to providing and staffing the primary care health centres which have only started to be rolled out and which are key to keeping people from being admitted to acute hospital services or institutional care.
GPs will be the first port of call and will not just work within a primary care team (level one) but also liaise with the myriad of other health and social care services in the health and social care network (level two); secondary care hospitals and urgent care services at level three; and tertiary care services, the “centres of excellence” at level four.
Indeed, the HSE is implementing policies whereby smaller county and general hospitals will cease to perform complex health procedures and will be “reconfigured” as day hospitals/urgent care centres or clinics.
Reducing the need for hospitals
All of these will be linked to primary and community care, with the stated aim of reducing the necessity for people to stay overnight in acute hospitals or even need hospital care in the first instance.
Other interventions such as “falls clinics” in the community for older people and enhanced geriatric community care, all liaising between primary care teams and health and social networks, are designed to keep people from being admitted to hospital or having to go into nursing homes.
Meanwhile, community mental health teams are planned, to liaise with primary care teams to fulfil the gold standard of keeping patients with mental illnesses at home and utilising the same objective for the general population, those with disabilities and others with chronic or acute conditions, such as diabetes, asthma and other illnesses.
By accident or design, given the foregoing policies, the relatively large number of GPs in Ireland, compared with the small number of hospital beds and specialists, is of critical importance; more so, given the lack of the latter. Also, people want to stay at home rather than go to hospitals, psychiatric wards or nursing homes.
Under all these circumstances, it is an abomination that GPs are being cut back, with the likely effect of driving hundreds out of business. Even before these proposed cuts, there has been a significant fall in their numbers in recent years. If the cuts go ahead, the closure of GP surgeries will happen in poorer areas where GMS patient numbers are highest. Already, there is a shortage of GPs in poorer urban areas.
Poor people, who live at least five years less than those on the highest incomes – and who possess the highest incidence of all illnesses across the various socio-economic groups, according to the Institute of Public health – will suffer most. Those in most need will be hit hardest.
Rarely has any Government in Ireland introduced such a regressive and negatively far-reaching policy, which works in the opposite direction to what is desirable given all the available evidence.
Dr Tom O'Connor is a lecturer in economics and integrated care at Cork Institute of Technology. He is the editor of the book Integrated Care for Ireland (2013), Oak Tree Press