Appendix 2

• Strengths and weaknesses of the current system

• The consultation process

• Overview of published literature

• Primary care systems in other countries

Strengths and weaknesses of the current system

Developments in primary care should build upon and add to the very significant strengths of the current system. GPs, public health nurses and other professionals have historically provided primary care in Ireland. They have provided a critical front-line service which has acted as a gatekeeper for many secondary elements of the broad range of health and personal social services. In many cases, and for long periods, it has been the commitment of such professionals in the absence of an appropriate infrastructure for primary care which has ensured that the public has been able to avail of a personal, local, accessible and timely service with which they have been satisfied.

Professional bodies such as the Irish College of General Practitioners, the Institute of Community Nursing, the Irish Practice Nurses Association, the Commission on Nursing and many others have developed initiatives to improve the quality of primary care services delivered to the public. There has also been a strong tradition of community and voluntary involvement in primary care service provision in such programmes as meals on wheels. Primary care infrastructure however remains poorly developed. Some of the principal inadequacies of the current system are shown below.

Principal inadequacies in current system of primary care

• Poorly developed primary care infrastructure and capacity

• Current system fragmented from user’s perspective

• Limited opportunities for user participation in service planning and delivery

• Emphasis on diagnosis and treatment with weak capacity for prevention and rehabilitation

• Potential to reduce pressure on secondary care not fully realised

• Secondary care providing many services which are more appropriate to primary care

• Current system oriented around needs of providers rather than users

• Out-of-hours services underdeveloped

• Limited availability of many professional groups

• Professional isolation

• Limited teamworking

• Communication between professionals and sectors inadequate

• Lack of quality assurance framework

• Limited information from primary care for planning, development and evaluation

Medical treatment services predominate and availability of other elements, e.g. social services, occupational therapy, physiotherapy, counselling, home help, etc. has been limited. Non-medical services are also provided during limited hours, except on a planned essential needs basis. General practitioners and other primary care staff often work in isolation and communication between the different primary care service providers is not optimal. This leads to public services that are poorly integrated and do not comprehensively meet the needs of individuals and communities in an appropriate primary care setting. Eligibility arrangements are also not clear with the exception of the choice of general practitioner. Information and communications technology is very underdeveloped. The potential of ICT to inform the public and to significantly impact on service delivery, especially the sharing of information between practitioners and continuity of care plans for patients across programmes of care, needs to be realised.

A comprehensive international evidence base is now available to assist in policy, planning and improvement of clinical care through the development of quality standards and accreditation in primary care. It also demonstrates that the public can be better informed about health and health services and that professionals can benefit in the areas of education and skills development.

The current capacity of primary care is insufficient to meet the evolving needs of the population. Changes in demography, reorientation towards prevention and health promotion and shifting the focus from secondary care towards primary care will increase the burden already facing community services. Commitment to change at many levels will be required to meet the challenges and build the appropriate capacity into the future.

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The consultation process

During the consultation process undertaken to inform the development of the Health Strategy, submissions were sought from the general public, organisations and health service personnel. A National Consultative Forum comprising approximately 180 members representative of key stakeholders in the health service was also established. A separate document, entitled Your Views about Health, has been published with the Health Strategy which gives full details of the consultation process. One of the issues identified in proposals from individuals, organisations and professionals was the need for improvement in services delivered in the community, and a much more flexible approach to delivery. The major messages emerging for each level of the consultation process are set out below.

Consultation with organisations

The need for enhanced community-based health services was raised in 31 per cent of submissions from organisations. The key themes running through the organisation submissions were the need for enhanced levels of a wide range of community services, local availability and local access as important dimensions of a quality service. The need for stronger linkages and connections within and between services, so as to create a holistic, seamless, people-centred service was also highlighted. Flexible out-of-hours support services for families was identified as a major concern. In the absence of comprehensive and flexible supports, the impact of caring on the health, well-being and family income of the carer was highlighted.

The case was made by many organisations for increases in the numbers and kinds of community health personnel working at local level: public health nurses, practice nurses, physiotherapists, occupational therapists, speech and language therapists, community health workers, women's health development officers, health psychologists and people offering medical specialties at community level.

Consultation with general public

Improvements in community health and personal social services were the subject of almost 2,000 proposals and accounted for 18 per cent of all proposals made in individual submissions. The main changes and improvements sought were: additional community-based services and community health professionals (GPs, nurses and therapists), improved health centres, local testing and screening, help lines, community-based counselling, local transport, improved access to complementary medicine and better linkages between services. The main requests in relation to GP services were for more flexible out-of-hours services, more group practices, greater access by GPs to diagnostic services and lower GP charges.

Consultation with health service personnel

Each of the ten health boards and the Department of Health and Children held focus group meetings and discussions with staff. One of the key recommendations, common across the submissions, related to primary care and community social services including improved access to GP services, a team-based approach to provision, priority for groups with special needs and improved linkages within the between services.

National Consultative Forum

At the second plenary meeting of the National Consultative Forum held in July 2001 the stakeholders were given feedback from the consultation process and a progress report on the development of the Strategy document. A presentation was given on the proposals for the introduction of a new model of primary care. Eight workgroups were established to consider some of the proposals in greater detail. One of the workgroups was specifically asked to consider the main obstacles and actions required to introduce the model of primary care. The workgroup recommended that the model be put into action, have implementation projects, resource the system, manage the relationships between primary and secondary care and evaluate the progress. The group recommended building on some of the local initiatives already introduced in parts of the country. During the feedback session at the end of the workgroup activity, the Forum endorsed the introduction of the proposed inter-disciplinary primary care team.

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Overview of published literature

The proposals outlined in this document are evidence-based. A literature review was undertaken to examine the evidence for the various components of this model such as teamworking, skill-mix, continuity of care, generalist versus specialist care, and telephone triage. A short summary of the review is presented below. The full literature review is available on request.

A team-based approach

The importance of a team-based approach to primary care has been acknowledged by the Royal College of General Practitioners (RCGP) in the UK and the Irish College of General Practitioners (ICGP) along with the Irish Medical Organisation (IMO) in their vision document. The European Working Group on Quality in Family Practice also identified team building as one of the major targets for development in primary care. A report recently drawn up by health professionals and patients in the UK presented evidence to show that teamworking provides a more responsive service to patients who benefit more when health care professionals work together. The importance of preserving the central role of the doctor-patient relationship in any developments in primary care has also been stressed.

Various studies have shown that the introduction of inter-disciplinary primary care teams are associated with the ability to keep patients at home in times of crisis, reduced emergency admissions, shorter lengths of stay for patients admitted and increased patient and carer satisfaction. Key areas to be addressed to ensure that teams are effective are: access to information, clearly defined team roles, and appropriate team size.

Team members

The RCGP in the UK identified the core primary care team membership as consisting of GPs, practice nurses, community nurses, health visitors, practice managers and administrative staff. They suggested that other members might include counsellors, midwives and psychiatric nurses. Clinical psychologists, physiotherapists, occupational therapists and dieticians should also be available to provide a range of services for patients. The important role of community pharmacy in the team has been acknowledged in many countries. The team composition might vary according to the needs of the population served and the individual patient. As the GP is the common link in all primary care teams he or she may assume a leadership role within the group. However, any member of the team can lead in circumstances where his or her skills are more relevant. As primary care team members often have an incomplete understanding of the skills of other team members, possibilities regarding shared education should be explored at undergraduate, postgraduate and practice team levels.

Skill mix

Skill mix is the use of a variety of professionals to carry out roles traditionally performed by one health care professional. It ensures that all team members are always working to their maximum professional capacity. Many studies have concentrated on one aspect of skill mix such as the introduction of the nurse practitioner. Patients have been shown to be satisfied with nurse practitioner consultations and the number of prescriptions issued and referrals to secondary care have been found to be similar to those that result from GP consultations. However, patients may prefer to continue to seek medical rather than nursing care.

Continuity of care

Continuity of care allows health professionals to get to know patients. This has been found to be associated with time saving, reduced referrals, reduced prescriptions and improved compliance. The literature also shows that continuity of care is associated with improved recognition and management of patients’ psycho-social problems.

Most research suggests that a patient’s satisfaction with a consultation is strongly associated with visiting the same doctor. Studies which have looked at out-of-hours care provided by GPs from the patient’s own practice versus those from deputising services have found that deputising doctors were less likely to give telephone advice, took longer to visit at home and were more likely to prescribe medication. Patients were more satisfied with services provided by their own doctors.

Generalist versus specialist care

The literature shows that generalist and specialist teams can work synergistically. Various studies have highlighted the potential of primary care teams working with specialist mental health services in the community. Studies have also shown that primary care providers are keen to become more involved in the care of those suffering from mental disorders and see the value of having a community psychiatric nurse working as part of the team. For stroke patients, studies have shown that early discharge with community support is as clinically effective as conventional care and is as acceptable to patients and, for patients with HIV, improved collaboration between primary care and specialist teams leads to a reduction in hospital lengths of stay.

The concept of shared care means that the members of the primary care team can work with other specialist groups in the care of individual patients. Shared care has been successfully employed in areas such as diabetes care, asthma care and palliative care. Important components of successful shared care include agreed objectives and locally developed written guidelines.

Gatekeeper role

GPs provide a crucial gatekeeper role to secondary care services. Studies have shown that patients value this gatekeeper role and it has also proved to be cost-effective. Open access to specialist clinics can lead to over-investigation and fragmentation of patient care. The ICGP/IMO vision document acknowledged this important gatekeeper role of the GP.

Telephone triage

Telephone triage is becoming a key point-of-entry tool for patients accessing the health system. It has been shown to be a cost-effective way of providing care which facilitates continuous access to primary care. Nurses are currently the key professionals providing this type of service. The introduction of decision support software can further improve the consistency of decisions taken by the nurses.

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Primary care systems in other countries

In developing a strategy for the development of primary care for Ireland, strategies for primary care in a number of other countries were examined so that components of successful models could be incorporated into the model. Some common themes emerged from all of the major strategies that were reviewed. These included

• the key role of inter-disciplinary teamworking

• the importance of preventive services

• the need for improved information

• the importance of patient enrolment.

The methods of funding and payment for services were disparate. Many of the changes proposed in the various strategy documents were facilitated by single-tier systems. A synopsis of the key features of the primary care services provided or proposed in a number of different countries is outlined below. The list of countries included is not meant to be comprehensive. A more detailed review of these and other international models has also been prepared and is available on request.

New Zealand

In February 2001, a new primary care strategy was launched in New Zealand. All people are encouraged to enrol with a primary care provider. Enrolment is voluntary. If persons choose not to enrol they will still be entitled to seek care but they may miss out on some preventive services.

The broad vision of primary care in the New Zealand Strategy means that no single practitioner or type of practitioner can meet people's needs completely. Providers of primary care services will involve doctors, nurses, pharmacists, midwives and a range of other practitioners with adequate numbers of managerial and support staff. The ability to recognise the role and importance of others, and to work collaboratively with them, will be essential.

The New Zealand strategy document also advocates improved co-ordination between primary and secondary care including increased primary health care access to secondary services such as diagnostic tests, implementing evidence-based guidelines with appropriate support from secondary services and developing local initiatives that bring together primary health care practitioners and hospital clinicians to develop better access to hospital services.

Canada

In Saskatchewan, Canada, a Commission on Medicare which produced its report in April 2001 recommended the development of an integrated system for the delivery of primary care services by

• establishing primary health service teams bringing together a range of health care providers including general practitioners

• integrating individual teams into a primary health network

• ensuring that comprehensive services, including a telephone advice service, are available 24-hours a day, seven days a week.

The commission stated that team-based delivery of primary health services is recognised around the world as the most effective way to deliver everyday health services. All provinces in Canada have launched primary health care demonstration projects, with doctors, nurses, therapists and social workers operating as inter-disciplinary teams, each contributing unique skills which, taken together, ensure a comprehensive range of services.

The Canadian strategy document acknowledged the fact that although most organisations of health care professionals support the idea of primary health teams there are different ideas about how these teams should work. The group outlined the practical steps necessary to make primary health service teams and networks work. These include the following:

• Primary health teams should include providers such as physicians, primary care nurses, home care nurses, dieticians and mental health nurses

• All members of the primary health team are responsible for ensuring that a comprehensive range of services is available to meet client needs. This consists of a standard set of services including 24-hour access

• Primary health practitioners are co-located whenever practicable, so as to promote a positive environment for integrated practice

• Primary health teams serve a defined population, with citizens free to choose or change providers.

The advantages for team members would be improved quality of working life, reduced on-call responsibilities, freeing up of physicians to make the best use of their training and expertise, opportunities for all members to employ their training and skills and closer integration with other health care professionals. A strategy document entitled Primary care reform: a strategy for stability was recently produced by the Ontario Medical Association. Some of the key features of this strategy document were:

• patient registration with a solo provider, group or agency

• implementation of an electronic patient record (EPR); EPR-information follows patient to all interactions within the health care system

• provision of 24-hour services, such as after-hours clinics or 24-hour telephone information

• economic incentives for integration of primary care. Inter-disciplinary teams encouraged through budget restructuring resulting in integrated organisation.

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United Kingdom

The composition of primary care teams in the UK varies from area to area. Some teams consist of GPs, nurses and practice administration staff, whereas others also have physiotherapists, phlebotomists, etc.

A document entitled Primary care, general practice and the NHS plan was produced in January 2001. This document acknowledges that the future of the NHS rests on the strength of its primary care. Some of the key points recommended in this report are:

• further development of flexible inter-disciplinary teamworking to deliver better services to patients

• the development of 500 one-stop primary care centres by 2004

• nurses undertaking more roles

• extending the role of pharmacists

• better use of receptionists and practice nurses to deal with coughs, colds and minor ailments.

The report states that nurses and health visitors will undertake a wider range of roles determined by patient and community need. They will be trained to take on more of the routine and minor ailment workload, enabling GPs to spend more time with patients and concentrate on those who need their expertise.

Australia

The Australian Medical Association (AMA) produced a position paper on primary care in January 2001. This document, while recommending an integrated team approach to the provision of primary care, stresses the central role of the general practitioner. The following are the key points:

• General practice should be formally recognised as the central discipline of medicine around which medical and allied health disciplines are arranged to form a co-operative primary health care team for the benefit of the individual, the family and the community

• The dominant clinical role of the GP must not be undermined in favour of that of a mere gatekeeper, administrator and coordinator

• Integrated care is the key to successful primary health care

• There is greater scope for a primary care role for nurses working within general practices as members of the primary care team

• GPs, as part of their primary health care role, should be involved in activities aimed at improving the health of the population, including programmes to prevent illness, public health screening and health promotion initiatives.

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Sweden

Treatment in Sweden is primarily hospital-based, with no clear distinction between primary and hospital-based care. There is no recognised system of family doctors and members of the public are free to refer themselves directly to hospitals in their region. Primary health care, however, has been greatly developed during the last decades. Active health promotion and systematic disease prevention programmes are considered to be as important as curative activities. Primary health care is organised around district health centres staffed by GPs, nurses, midwives and sometimes specialists.

Norway

GPs are considered to be the foundation of health care in Norway. Patients need referral from a GP to receive treatment at hospitals: thus, the GPs are used as gatekeepers for hospital service. GPs are organised in units providing not only curative treatment but also public health services, after-hours home visits and other services.

The Netherlands

Health care in The Netherlands is provided by thousands of institutions, tens of thousands of contracted or self-employed health professionals and hundreds of thousands of other health workers. Most health care facilities are owned and managed by not-for-profit, non-governmental entities of religious and charitable origins. As a rule, they have self-appointed boards responsible for overall policies and budget approval, but the management bears responsibility for ongoing daily business. Most GPs work in small group practices, and there are a small number of health centres where they work with other health professionals. Almost all dentists have a solo practice. Physiotherapists outside institutions usually work in small group practices. Most other health professionals are employed by hospitals or other health care facilities and organisations.

The Ministry of Health provides financial support for the introduction of information and communication technologies, for example by providing subsidies to GPs for computer practice systems. Until 1989, GPs needed the permission of local authorities to set up a new practice, but this requirement no longer applies.

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