02 June 2017
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Business Post article: 'General practice must be at the heart of a reformed healthcare system' - ICGP

This article was published online by the Business Post on 2 June 2017

With vision and investment our health service could change for the better, writes Dr Mark Murphy of the Irish College of General Practitioners.

Imagine you are in the waiting room of a busy general practice anywhere in Ireland today. What do you see? A wide range of people, a broad spectrum of ages, with a large range of possible illnesses and conditions.

It's a bustling practice, with busy doctors, busy nurses, a busy office. Every day, family doctors see at least 35 patients, and that does not include nursing homes or house calls. Each consultation generates an average of 3 conditions, and nine out of ten are sorted on the spot. Just one in 10 are referred onwards.

Doctors review and sign an average of 15 to 30 repeat prescriptions, most with multiple items, while practice nurses see similar numbers for immunisations, bloods, dressings and cervical smears. Both doctors and nurses manage a myriad of results and questions on a daily basis.

In the course of a year, Irish GPs carry out 25 million consultations, according to a 2013 study. That's likely to be even higher now.

Most patients get to see their doctors on the same day, something we still take for granted in this country. That's day in, day out, five days a week, and GPs also successfully provide an out-of-hours service in the evening, at night-time and at weekends, 365 days of the year.

The gatekeepers

Our general practitioners are the gatekeepers to a complex, fragmented and unfair healthcare system. Every day, we manage your health - and we want to do more. We take care of families - from the cradle to the grave - and we are the backbone of our health service.

And we need to do more. Our population is growing, and it's ageing. Our health care is becoming more complex; many of us have more than one medical condition, and we have a growing choice of drugs to help us stay well for longer.

But family doctors are being held back - by a number of obstacles, including the obvious financial one. We can't hire more practice nurses because we don't have the money; we lost 30 per cent of our government income from the cutbacks under the financial emergency legislation after the banks collapsed; we can't find replacement doctors to allow us to take a day off or go on holidays because our younger colleagues are emigrating in increasing numbers.

We want to provide a more comprehensive community-based health care for the chronically ill - those with diabetes, heart disease, cancer, depression, addiction, dementia, arthritis - instead of sending patients to the outpatient departments of major hospitals. But our existing out-dated contract with the government - currently under negotiation - doesn't cover the management of multiple chronic illnesses. That has to change.


But what really has to change is the hospital-centric nature of our healthcare model. Daily, hundreds of our major hospitals - centres of excellence in healthcare in a range of specialisms - are being held back while patients are turned into a statistic, waiting on trolleys in the corridors, instead of doing the work they are being paid to do.

Hundreds of thousands are on a waiting list for an outpatient appointment. Sometimes the reason behind the statistic is as simple as a GP not having access to a scan or a practice nurse not being able to manage a patient's chronic illness as this is not permitted in a contract. It's the norm in other OECD countries that diagnostic tests are done in the community - not hospitals.

Our major hospitals and centres of excellence have their own capacity difficulties - but they are being held back. They are clogged with patients who should have been treated and cared for in their own community first, in their own family practice or primary care centre. What a waste of money and talent.

What's also wrong is that 55 per cent of the population have to pay the full cost of their own primary care, and many - the squeezed middle included - can't afford the cost of seeing a doctor or filling a prescription, so they wait until they are so sick, then they go to the Emergency Department to be treated in a hospital.

Some parents must pay over €1,000 so their adolescent child can seek psychological supports. What a waste of resources and time! This is wrong.

But with vision and investment this could all change, for the better.

A single-tier model for the future

This week saw the publication of an ambitious, wide-ranging report on the future of our healthcare system in Ireland. Everyone with an interest in their own health and those of their dependents should read this, if only because it represents the hard work of a cross-party group of politicians who want what we should all want: a healthcare system that's available for those who need it, where they need it, and when they need it, irrespective of their income or address.

The Report of the Oireachtas Committee on the Future of Healthcare calls for the creation of a model of healthcare where the vast majority of care is provided in the community - a universal single-tier service - and where patients are treated on the basis of medical need rather than on ability to pay.

In other words, provide free general practice and primary care for all (not just the under 6s and the over 70s, and those with medical cards) which is the norm in almost every other OECD country, and end the situation we have now: where those who need care most are the least likely to be able to afford it.

But enacting this policy, given the significant erosions in the capacity of the general practice system, will be very difficult without significant and sustained financial investment - in people, infrastructure, and IT systems. Otherwise this report will suffer the same fate as many other reports- gathering dust, without being implemented.

At a crossroads

The Irish College of General Practitioners welcomes this re-orientation of our health service to ensure equitable access for all our citizens. We hope that the political consensus emerges to support this approach.

We are at a crossroads. Few people believe the current model can continue; healthcare and health insurance is becoming unaffordable for more and more of our citizens, while waiting lists and waiting times grow.

The Irish College of General Practitioners (ICGP) wants to make primary care accessible to all - but this can only happen if there are the proper resources to build capacity and infrastructure.

It will take time, and money. We hope the political will is there to do that, for all our sakes.

Dr Mark Murphy is the ICGP's chair of communications and a family doctor. The ICGP is the professional and training body for general practice in Ireland. There are 4,156 members, representing 85 per cent of practising GPs in the Republic of Ireland.

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