Every Irish town was to have comprehensive primary care services by now, but this has not been achieved. Why?
BACK IN 2001, the Government launched its primary care strategy , A New Direction. The strategy proposed the introduction of a multidisciplinary team-based approach to primary care provision where members of the primary care team (PCT) would include GPs, nurses/midwives, physiotherapists, occupational therapists and administrative personnel.
A wider network of other primary care professionals such as speech and language therapists, community pharmacists, dietitians, social workers, dentists, chiropodists and psychologists were also to provide services for the enrolled population of each primary care team.
Ten pilot primary care centres staffed by PCTs were subsequently set up providing convenient, holistic care for patients in the community.
Following the creation of the HSE, then chief executive Prof Brendan Drumm announced ambitious plans for a network of 530 primary care teams to be rolled out across the State by 2010/2011, and there were many photo opportunities during his tenure where he was pictured launching new centres.
However, just over 10 years after the launch of the strategy and the passing of Prof Drumm’s deadline, it is clear that the State’s great primary care vision has not come to fruition. A glance at the HSE’s most up-to-date performance report shows there are 425 PCTs across the State within an undefined number of centres.
The HSE claims they provide services to a population of more than 3.4 million with 3,117 staff members and over 1,592 GPs participating.
This is a dramatic improvement on the figure of 348 teams at the end of 2010. However, the HSE admits these teams are at various stages of maturity and development.
The definition of a team was adjusted a few years ago to count teams at the very early stages of development that had merely held a few meetings. This move was labelled as a “farce” and “the emperor’s new clothes” by many medical observers at the time.
Furthermore, most of the current PCTs are “virtual” in nature, meaning they are not housed within the same building and are spread across many sites.
GPs are self-employed contractors as opposed to State employees and aren’t always keen to be herded into communal buildings while the HSE’s lack of access to capital funding means that rolling out purpose-built, state-of-the-art centres has not been possible.
The development of the teams has also been hampered by the fact that they lack a centralised communication and ICT system so agreeing information- sharing protocols has been a slow process, while the recruitment moratorium, the early retirement scheme and shrinking HSE budgets have also taken their toll.
The HSE says an additional €20 million has been made available for primary care recruitment in this year’s budget to improve PCT services. However, 111 GPs in the northeast recently informed the Department of Health of their intention to immediately cease all involvement in PCTs due to a number of industrial relations issues, which does not bode well for the year ahead.
IMO president Dr Ronan Boland says his definition of a functioning PCT is one where the patient has access to additional healthcare services and it is clear that a large amount of the HSE’s current PCTs do not provide this.
“Unfortunately, the majority of teams veer towards the early development stage and certainly from serial surveys of GPs, the majority feel they are either not really in a team or are in one that is not achieving its full potential.”
Dr Boland, who is part of a PCT in Cork city, says his is now functioning well enough with modest access to allied health professionals though the recruitment moratorium has affected it.
He doesn’t believe there will be many new primary care centres opened in the next couple of years “as GPs are having difficulty paying the bills let alone investing in practice infrastructure”, even if the HSE is willing to rent out centres developed by third parties and GPs themselves.
It is clear, however, that where primary care centres have been opened, they provide an excellent range of services to patients, enabling them to access most of their health professionals in the one building with many even facilitating consultant outpatient appointments, X-rays and other scans, minor injury clinics, pharmacies and other healthcare services.
One self-developed centre is the Mallow Primacy Healthcare Centre which houses three separate PCTs within a large centre incorporating the latest medical technology. It opened in May 2010 and was developed by the GPs themselves over a number of years. One of the centre’s founders, Dr David Molony, said it was a long, hard process to open the centre but it now provides a comprehensive range of health services to local patients.
The centre offers chronic disease management services and proactive healthcare for its patients, such as monitoring the condition of its elderly patients, which Dr Molony said saves on hospital admissions and other health costs down the line. Currently, the HSE’s long heralded plan to provide chronic disease management in primary care is patchy and only available for certain diseases in some centres.
Since the onset of the recession, attempts to roll out other large privately- funded primary care centres have run into problems.
In January the primary care centre development company run by Dr Seán McGuire, a special adviser to Prof Drumm between 2005-2007, was placed into examinership.
Prime Healthcare opened its first centre in Carlow in October 2009 and its second centre in Killarney in January 2011. It is currently working on developing a number of other centres with GPs and the HSE.
High rental costs and property development issues are understood to be at the centre of the financial problems affecting the company.
The Killarney centre has also had a number of planning issues, meaning a lot of the space intended for allied medical professionals and a pharmacy currently remains unoccupied so it is missing out on vital rental income, though it is currently awaiting an appeal decision by An Bord Pleanála, due in late March.
A spokesperson for Prime Healthcare said they were very confident the company would emerge from the examinership in the coming months “in better shape than ever”, but acknowledged that finance remained a significant challenge for primary care developers in the current climate.
Another primary care centre development company, Touchstone, has also had its fair share of problems. Back in 2004, its chief executive, Fergus Hoban, announced ambitious plans to roll out a network of 60 large-scale primary care centres within 10 years.
Despite initiating plans for a number of centres in Dublin and big towns around the State, the company was hampered by expensive property prices, planning issues and then the collapse of bank finance following the recession.
Touchstone currently only has one centre open in Dublin but remains hopeful of developing more as construction and property costs are now far more affordable. However, bank finance remains a problem and other funding sources are now being pursued, Mr Hoban said. The company has also started working on developing primary care centres in the US.
Meanwhile, the HSE said the governance and management model of PCTs is currently being reviewed to take account of the models of care proposed under the Programme for Government. So it looks like the grand vision of primary care services being delivered by PCTs in big state- of-the-art centres in every town in Ireland is still a long way off.