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ICGP AGM
Squaring the circle on
healthcare reform
While hard-pressed GPs agree they are the solution, they feel they must be
given the resources to achieve Dr Reilly’s goals. Niall Hunter reports
Pictured above at the ICGP AGM in Galway were (l-r): Dr John Delap, ICGP chairman; Kieran Ryan, ICGP CEO; Health Minister Dr James Reilly; and
speakers at the AGM debate: Dr Ronan Boland, president of the IMO; Prof Frances Ruane, director of the ESRI; Dr Margaret O’Riordan, ICGP head of
quality and standards; and Dr Joe Clarke, national primary care lead, HSE
“We have nothing to fear but fear itself,” Franklin D
Roosevelt once said as he tried to steer the United States
out of economic depression.
It’s one of those quotations that sounds impressive until
you actually analyse it. If GPs took it to heart and decided
not to fear fear, they would have the difficult task of ignoring the big mammal in the room – the spectre for some
of near-bankruptcy, the burden of excessive workload and
considerable uncertainty about future reforms.
Ireland Inc’s and Irish general practice’s ‘challenging’ and
very uncertain future was evident at this year’s AGM, where
health policy reform was the preoccupation. New Health
Minister and GP James Reilly received a warm welcome and
described his reception in Galway in a packed auditorium
as a ‘sweet moment’.
The new Minister is trying to reform healthcare despite
empty State coffers and dwindling income among overworked GPs. He would be the first to admit that he may not
receive quite so enthusiastic a welcome at future AGMs,
particularly if his universal healthcare vision turns to dust.
Dr Reilly’s message was essentially that of the US President’s in the early 1930s – don’t be afraid to embrace
the future. General practice would be at the centre of the
changes planned. Unfortunately, following his address,
the Minister had to leave for another engagement and did
not get to hear the concerns in the ensuing presentations
and debate. After the top table had spoken and the debate
was thrown open to the floor, many caveats and concerns
emerged in what was an unusually fractious atmosphere for
a College debate.
Reaching Dr Reilly’s new horizon is clearly not going to
be plain sailing. Fears were expressed about the GP workforce shortage being addressed, about the structure of the
reforms, about practices already near financial breaking
point, of yet more work and more income cuts being thrust
on GPs as they are politely asked to light the fuse for a
revolution in healthcare provision. Given that many of the
changes the new government is proposing can be found in
the College’s ‘blue book’ back in the late 1980s, the mood
of the audience seemed to be – ‘this is all very well, but it
couldn’t have come at a worse time’.
Quality care
Another message from a very informative reform debate
was that the issue is ultimately not about money (or lack
of it) in GPs’ pockets, but about maintaining adequate
resources to continue to deliver quality care to patients.
The Minister said during his time as a GP over the past
20 years or so, he has seen the continent of healthcare in
Ireland break up into a thousand little islands. Getting a
patient from one island, the surgery, to another island, a
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Members listen to Minister Reilly’s address
a hospital bed, became increasingly difficult. During this
time, he noted, a positive development had been the establishment of the College. The Minister paid tribute to Fionán
Ó Cuinneagáin and wished the best of luck to his successor
Kieran Ryan. The ICGP, the Minister said, always put the
patient front and centre. “The problem was that the system
forgot that key imperative. But that’s what systems do –
they start out with the best intentions and end up serving
themselves.”
Dr Reilly said that was why he went into politics – an
absolute frustration with the healthcare system, with its
preoccupation with acute hospitals and no understanding
of the critical role of general practice.
The Minister promised the previous lip service to a primary
care strategy would now change, and while acknowledging
that some progress had been made, he challenged the HSE
on its estimate of the number of primary care teams that
actually existed. He said the pace of development of primary
care had to be accelerated. The Minister said with IT developments, multidisciplinary care can be delivered through
smaller practices more geographically spread, which can
be linked together: “This government will turn the system
around so that it starts where it should start, with primary
care.”
He said progress on the ‘fast-track’ process for GP training for doctors with the relevant hospital training needed
to be made by September this year. This was partly due to
the fact that increasing GP numbers was part of the EU/
IMF recovery programme, and also because it made sense.
He said GMS entry would also be opened up as it made
no sense to have fully-trained GPs unable to treat medical
card patients. On free GP care, he said this system would
be introduced in a phased way by supporting primary care
to prepare for this major initiative, dealing with issues such
as GP workforce levels.
The Minister said any changes ahead would be based on
consultation, compromise and conciliation. In improving
the system, Dr Reilly said, the involvement of GP leads in
the clinical programmes would be crucial. The new contract would place increased emphasis on prevention and
on managing chronic illness. It would also include more
family-friendly work options. The Minister, speaking to journalists afterwards, said resources moving from secondary
care as a result of the planned reforms could be used to
bolster general practice infrastructure and development. It
remains to be seen how easily these resources will be given
up by the hospital sector.
Challenges
Prof Frances Ruane, director of the ESRI, was well-placed
to outline the challenges in reforming the system, having
chaired the expert group that drew up last year’s report on
resource allocation and financing in the health sector. She
told the meeting that current practices and arrangements in
the health service must evolve to give us a workable healthcare system. The current system, she said, was disjointed
and there was a need for an integrated and coherent system
that the patient can easily navigate.
Primary care, said Prof Ruane, is the key to the provision
of patient-centred care. However, she said GPs face challenges as part of this major shift in care provision. They
would have to move to be part of a more integrated system;
agree to new contracts with monitored deliverables and
appropriate compensation rates including incentives; work
more in teams with other professionals and make greater
use of technology to increase efficiency.
Prof Ruane suggested that new GP contracts could be
made varied and fit for purpose. She said primary and community services needed to be developed and strengthened
and resources shifted from hospitals where appropriate.
She outlined the proposals from the expert group involving
a stepped system of healthcare cover.
IMO president Dr Ronan Boland said primary care teams
must be properly resourced and this was a key issue if
workload was to be transferred from hospitals. He said the
development of new chronic disease programmes with GPs
playing a pivotal role will require a new contractual framework, by way of a single contract or a suite of contracts.
Dr Boland said the IMO’s vision was of a comprehensive
primary care service with the patient at the centre. The IMO
is working with the ICGP on a joint strategy to deal with
the move from ‘vision to reality’. He said given the current
straitened financial times, the IMO was exploring how general practice could work more leanly. Dr Boland said while
GPs could do more in a better organised health service, this
will require adequate resources, not just in terms of extra
doctors but in terms of support infrastructure.
Co Meath GP Dr Joe Clarke gave ‘the view from the bridge’
as national primary care lead at the HSE. He said while
primary care had been the ‘buzz words’ over the past 10
years, there had been much lip service paid to it. Dr Clarke
said the Programme for Government provides for a new GP
contract to give incentives to GPs to care for patients with
chronic illnesses more intensively.
A recent national mapping exercise by the HSE indicated
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Pictured at the AGM were (top): Dr Sheila Rochford and new College
vice-president Prof Bill Shannon; and (above) Drs Bridget Sheehy and
Ide Delargy
the extent of the manpower problem that exists in general
practice and the need to address these issues as healthcare is realigned. If all the GPs who are 60 plus years old
decided to retire now, ‘we would have a major catastrophe
on our hands’, Dr Clarke said. He said there were not enough
nurses working in primary care. In his opinion, chronic care
should be GP-led but primarily nurse-delivered.
Dr Clarke said it was important that the College had
stepped up to the mark and shown a major leadership role
in appointing GP leads to the clinical programmes. It is
proposed that the chronic disease component of the new
contract would be called ‘chronic disease watch’, on similar
lines to Heartwatch, he said. This would have set targets,
including a 50% reduction in bed day rates and a 95%
reduction in unplanned admissions.
Margaret O’Riordan, the College’s head of quality and
standards, painted a clear picture of the burdens already
facing general practice even before change is embraced.
She stressed the need for a sustainable GP workforce to be
maintained in order for the goals to be reached. Moving for
a minute from lofty strategies and aspirations, Margaret outlined the reality: 16 million GP consultations every year.
“I think it is the experience of everybody in this room that
we are getting busier on a daily basis and I strongly suspect
that the 16 million consultations are on the increase.”
Margaret pointed out that GPs are working with a contract
that provides only for an acute illness intervention service.
GPs around the country are also providing primary prevention and chronic disease management. They are the only
group that can deal with multimorbidities and also cater for
disadvantaged groups in the population.“None of this work
is acknowledged in the current GMS contract.”
Other challenges included recent fee reductions, and
the ‘leakage’ of hospital care to general practice. Adding
to these challenges were new professional competence
requirements and likely HIQA inspections. Margaret said
GPs are working in an extremely challenging environment
both for themselves and their patients.
“In the current environment, sanitised words like ‘recession’ and ‘negative equity’ translate into a human face in
our surgeries on a daily basis. Therefore, we are dealing
with people trying to deal with anger, frustration, stress and
even despair, and that does not make our job easy.”
Looking ahead, Dr O’Riordan said if GPs stick to their
principles they cannot go far wrong. These are a focus on
quality, equity, access and service to the patient. “It is
important to be realistic here and to say that in order to do
this we need time and resources to support general practice. We also need time and resources to support primary
care – they are not the same thing.”
Outlining the progress of the new clinical programmes,
she said the GP leads appointed to date have been actively
contributing to the programmes on asthma, COPD, epilepsy, diabetes, heart failure and stroke. She said proper
IT was essential for the success of the planned integrated
care approach. Dr O’Riordan concluded that with appropriate support, general practice can be at the centre of a high
quality, integrated, and person-centred health service.
Speaking from the floor, Dr Mary Favier, who works in a
deprived area in Cork city where nearly all the patients are
on the GMS, said bluntly her practice was ‘going broke’.
“We have always been committed to high quality patient
care. We have for the first time made decisions that we will
have to put our finances first and reduce the quality of care
being delivered to our patients,” she said. Dr Favier said
she felt many GPs at the meeting were making similar decisions or would be making them within the next six months.
She said until there was a guarantee that the new model
will work in areas of deprivation, the goodwill and commitment of the vast majority of GPs could not be counted on.
Dr Ray O’Connor from Limerick felt there was no incentive for younger doctors to work in deprived areas.
Dr Declan Larkin from Limerick said he felt he already
worked ‘bloody hard’ for what he did and provided a fantastic service at a very low cost to the State. Some of it was
pro-bono work and was not recognised, yet the typical GP
was being portrayed in the media as a ‘rich fat doctor’.
The manpower issue was raised by Dr Peter Wahlrab
from Co Meath, who said some of the fastest growing areas
of population were the least doctored. He was concerned
whether the plans to improve the manpower situation would
deliver the number of doctors needed to provide an integrated primary care chronic disease system
Prof Tom O’Dowd of TCD said if GPs really wanted to be
at the centre of what is going on they have to be included in
the governance structures. He warned of difficulties ahead
when the necessary transfer of funds from secondary to primary care started to happen.
The debate would have given the Minister much to think
about, had he been able to stay for all of it.
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