Reform of primary care in Ireland has been on the agenda for several years. The first permanent HSE chief executive Prof Brendan Drumm quickly identified the sector as a key to developing and unblocking our health service. But despite his considerable efforts, and those of many others, nothing concrete ever happened.
It is also true that no sector in Irish public life has had as many reports into it as has the health system. You can count on one hand the number that have been acted on. The rest are stacked high and wide in the corridors of the Department of Health.
Statistically, then, the odds against today's report – A Future Together: Building a Better GP and Primary Care Service – making a difference are high. For many reasons, that would be a mistake.
The current health system is seen as fragmented, poorly developed and unfair. Real reform requires a decisive shift towards general practice. For such a shift to occur, the State needs changes in its contractual arrangements with general practitioners as a first step towards wider changes in primary and community care services.
At the outset of their commission, the Trinity College Dublin authors of the report were given a contractual focus. But somewhere along the way, in the words of John Hennessy, national director of primary care with the HSE, the report “broadened from an information exercise for the new GP contract, to a wider look at the development of the primary care system”.
Straining at seams
“We have now arrived at a confluence of opportunity to redress the balance: our hospitals are straining at the seams, we have a recovering economy and the international evidence for primary care systems is hardening,” he says.
The report is multilayered: a mix of original research among the public and health professionals as well as a trawl through international evidence for the strength of primary care. Some observers will be surprised at the US-centric nature of many of these references, with data from primary care developments in Vermont and North Carolina deemed more reliable than EU sources.
Beyond the welcome vote of confidence in general practitioners and practice nurses from the report’s canvassing of the public lie some important nuggets for meaningful reform: the majority of GPs felt that the current medical card contract should be more reflective of the time spent with patients; and access to diagnostic services in the community is now so poor as to be cited by GPs in training as a reason for discontinuing a career in general practice.
The report cites good evidence that seeing the same primary care doctor regularly results in significantly fewer admissions for patients with multiple long-term conditions. But it requires additional consultation time which must be a feature of a new GP contract.
Medical cards
Private health insurers, and their avoidance of real engagement with general practice, also feature in the report. Given that 60 per cent of the population does not have any type of medical card, the insurance companies must be put under pressure to better fund payments to non-medical staff for practice-based services.
The evidence cited by Prof O’Dowd and his co-authors supports a decisive shift to GP-led primary care, which in turn is the key to transformation of the health service as a whole. “A move to primary care is a philosophical, political and financial journey that challenges a society impatient for better health services,” they write.
It won’t be an easy journey. We have missed the reform train on so many occasions. Is there a consensus among politicians, policymakers and practitioners that this time will be different?