The Recommendations for Primary Care document, recently leaked to The Irish Times, deserves thorough public debate. The Irish College of General Practitioners (ICGP), which represents more than 90 per cent of Irish GPs, welcomes this opportunity to contribute to it, even in the absence of a full published text.
It is a curious irony that general practice - the part of the health service that has no waiting lists, sees public and private patients without distinction, and provides real consumer choice and personal continuing care - is the part everyone seems determined to change.
Nevertheless the ICGP will consider any evidence-based reforms likely to benefit patients. Some reforms, such as a central role for primary care, would be welcome. Of course any reform should improve general practice, and not merely solve the problems of the hospital sector.
Primary care cannot be considered in isolation. For balanced debate, proposals to reform both the hospital sector (public and private) and healthcare management should also be published.
Any move to change general practice should first recognise its strengths and ensure these are not undermined by any reform.
The first and most important of these is choice for the consumer. Most general practice patients can change to another doctor if dissatisfied. This means they cannot be treated the way some patients are treated by the public hospital system. They are not arbitrarily assigned to a catchment area and compelled to use one service. Any reform that changes general practice into this kind of service monopoly will seriously weaken the power of patients.
The second strength is that general practice provides personal care. Our expertise lies in tailoring healthcare to the individual we know. We ensure that each patient gets treated fairly, according to his or her needs. Patients will not welcome a move to impersonal care.
The third strength is that GPs, as frontline clinicians, also usually own and manage their practices. There are no management hierarchies to delay sensible practical improvement. Decisions can be made quickly and cost-effectively at local level by those who know and understand the needs of service delivery. Time and resources spent on bureaucracy are minimal. Reform that imposes on general practice the burgeoning management and administrative structures of the public health services should be rejected.
Most GPs are paid by individual patients, health insurance companies and the State. Yet all patients, however paid for, attend the same practice and see the same qualified doctor of their choice every time and without undue delay. Perhaps the hospital system should be organised along similar lines.
The manner in which doctors are paid can also distort clinical priorities. Irish general practice combines the fee for service with capitation payments and allowances. This balanced payment system has been shown to work best. Salaried systems do not encourage optimal performance; pure fee-per-item systems lead to unnecessary diagnostic and treatment procedures. The current system should remain.
Some of the reforms proposed are necessary. Changing the eligibility limit for medical cards to include patients caught in the poverty trap, or providing everyone with some preventive services free, are worthwhile. However, giving medical cards to the whole population in an NHS-style service is unnecessary on grounds of equity, wasteful in terms of cost-effectiveness and damaging to quality. Our health services should be deregulated, not nationalised.
Reports from GPs in the British NHS describe a GP service inappropriately overused, with demoralised staff, and typical waiting times of more than 10 days.
Most Irish patients have no difficulty accessing their GPs and don't need 1850 numbers to do so. Out of hours, their doctor refers them to another service. Well-organised GP co-ops providing high-quality out-of-hours services are operating or planned in many areas.
There is little evidence that telephone helplines such as NHS Direct reduce the demand for immediate care services. Giving advice to a patient you do not know and cannot see would be regarded as dangerous practice by most GPs.
Of course general practice can be improved. Many practices could provide more sophisticated services at local level if GPs and practice nurses weren't so busy. Unprecedented patient demand increases referral rates to hospital. Paying practices to provide more sophisticated services would increase the number of GPs and practice nurses and reduce hospital waiting lists.
Teamwork is important. GPs, practice nurses and public health nurses all provide a generalist service. Together they constitute the generalist team. The Irish College of GPs, in consultation with nurses' groups, is proposing trials of teamwork for several health board areas.
As true generalists, the doctor or nurse must be open to any problem the patient chooses to bring. More than 90 per cent of these can be solved without referral. Generalist expertise is based on knowledge, built up over many years, of the individual, the family and the community. This, combined with the skill to diagnose and treat most common problems, and then refer appropriately, enables the generalist to manage 90 per cent of patient contacts with the health services.
In contrast, specialist expertise comes from providing diagnosis or treatment confined to a particular clinical area. Even within their specialist area, only rare and difficult problems need their expertise. The efficacy and efficiency of specialists therefore depends on the pre-selection of suitable cases which referral provides.
Direct access to specialists is a wasteful use of a limited resource. Direct access to physiotherapists and occupational therapists would swamp their services. Those who really need such services would join queues made longer by those who don't.
Better integration of healthcare and personal social services is desirable. Much of general practice has a social care dimension. Some social problems encountered in practice require social service intervention or the skills of an accredited counsellor.
Formal referral remains the best way to achieve this, provided there is good co-ordination and communication before, during, and after the service is provided. Grouping professionals into large unwieldy teams for time-consuming, costly meetings is not the way.
Adding a plethora of community-based specialists to the generalist team completely misses the point. Teams should be small, in close communication, working from a common patient record, and share a person-centred approach that provides continuity and comprehensiveness. Above all effective care must be built upon a personal relationship of trust and accountability. No one wants to be cared for by a committee.
Much lip-service is paid to the central role of primary care. To make it really central, secondary services (those accessed only by referral) must be made accountable to primary care. This will not happen until patients and their GPs have a choice of public hospitals. Competition between hospitals must be restored.
Accountable hospitals should focus on efficient, acceptable routine management of common conditions for the majority in addition to the expensive, highly specialised intensive care of the few. Less expensive hospitals should be available to provide convalescent care and rehabilitation, particularly for the elderly.
GPs and generalist nurses must also have direct access to those diagnostic and treatment services currently available only through specialists. If primary care is to be central the decision to admit patients to hospital must be largely restored to GPs, and the provision of routine primary medical care by accident and emergency departments must cease.
Practices grouped in co-ops, each with a list of registered patients, enable community or hospital-based specialist services to be organised into competing teams serving a defined population.
The college welcomes the overall thrust of these leaked proposals. However the devil is in the detail. Some specific reforms would damage aspects of general practice which patients value. Some of the ideas borrowed from abroad are either unnecessary or without proven benefit.
Fundamental change will be required over the next 10 years to address the crisis in our public hospital system. Placing primary care at the centre of our health service is the right way to start.