Executive Summary

Introduction

Primary care is the first point of contact that people have with the health and personal social services. The Health Strategy 2001 sets out a new direction for primary care as the central focus of the delivery of health and personal social services in Ireland. It promotes a team-based approach to service provision which will help to build capacity in primary care and contribute to sustainable health and social development.

The aims of the proposed developments are: to provide (a) a strengthened primary care system which will play a more central role as the first and ongoing point of contact for people with the health-care system, (b) an integrated, inter-disciplinary, high-quality, team-based and user-friendly set of services for the public, and (c) enhanced capacity for primary care in the areas of disease prevention, rehabilitation and personal social services to complement the existing diagnosis and treatment focus.

Primary care in context

Primary care is the appropriate setting to meet 90-95 per cent of all health and personal social service needs. The services and resources available within the primary care setting have the potential to prevent the development of conditions which might later require hospitalisation. They can also facilitate earlier hospital discharge.

Primary care needs to become the central focus of the health system. The development of a properly integrated primary care service can lead to better outcomes, better health status and better cost-effectiveness. Primary care should therefore be readily available to all people regardless of who they are, where they live, or what health and social problems they may have. Secondary care is then required for complex and special needs which cannot be met solely within primary care.

The need for change

Primary care services offer great potential to achieve the growth and development in service provision that the Health Strategy is seeking to achieve. Their wide availability, their locally accessible and personal nature facilitates a close on-going relationship between providers and users of the service. Although many aspects of primary care services are satisfactory, nevertheless the current system has a number of deficiencies. Primary care infrastructure is poorly developed and the services are fragmented with little teamwork and limited availability of many professional groups. Liaison between primary and secondary care is often poor and many services provided in hospitals could be provided more appropriately in primary care. Out-of-hours primary care services are underdeveloped at present.

Many countries are now developing primary care services as the cornerstone around which their health services are built. These countries are implementing strategies which highlight the importance of a team-based approach to primary care. There is evidence in the published health literature of the success of team-based primary care which incorporates an appropriate skill mix.

The consultation process for the Health Strategy called for an improvement in services in the community.

The need for improved integration of services so as to create a seamless, people-centred service was specifically identified.

The Health Strategy, therefore, proposes to develop the capacity of primary care to meet the full range of existing and future health and personal social service needs which are appropriate to that setting. There will be a significantly enhanced commitment to the funding and infrastructural development of primary care. This will ensure a more equitable, accessible, appropriate and responsive range of basic health and personal social services for all. It will also enable primary care to lessen the current reliance on specialist services and the hospital system, particularly accident and emergency and out-patient services.

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Model of primary care

The Health Strategy proposes the introduction of an inter-disciplinary team-based approach to primary care provision. Members of the primary care team will include GPs, nurses/midwives, health care assistants, home helps, physiotherapists, occupational therapists, social workers and administrative personnel. A wider primary care network of other primary care professionals such as speech and language therapists, community pharmacists, dieticians, community welfare officers, dentists, chiropodists and psychologists will also provide services for the enrolled population of each primary care team.

The population to be served by a team will be determined by encouraging GPs to join together their existing lists of enrolled individuals and families, within certain geographic considerations. This geographic focus will strengthen the capacity of the primary care team to adopt population health approaches to service provision. Teams will be based in single locations where possible and will be easily accessible. Individuals will be encouraged to enrol with a primary care team and with an individual doctor within the team. Many services will be provided on an extended-hours basis and out-of-hours cover for defined services will be greatly enhanced. There will be an increased emphasis on prevention and rehabilitation as well as the traditional focus on diagnosis and treatment.

Liaison between primary and secondary care1 services will be improved. The primary care team will have better access to hospital services. Discharge planning will also be improved, with the development of individual care plans and the identification of key workers for individuals when appropriate. Integration between primary care and specialist services in the community will be strengthened.

The introduction of a team-based approach to primary care will have advantages for users and providers.

Requirements for implementation

This model of primary care represents a change in emphasis from secondary care to more appropriate primary care services that provide a single point of entry to all health and personal social services. Such a fundamental change will require major investment in human resources, physical infrastructure and information and communications technology. It will also require commitment and support from the various providers. The model described sets out the principles for progress but does not purport to address all of the detailed issues that will need to be worked through in the implementation phases.

The model will be implemented on a phased basis initially through implementation projects located around the country. The model will be refined and developed by agreement and on-going evaluation in which partnership with all stakeholders will be critical. Locations will build upon existing infrastructure where possible to ensure their success and will allow the development of the wider network of primary care providers for those primary care teams. Various models of teamworking will be applied in the implementation projects and participation will be on a voluntary basis.

The model will require new ways of working for providers who deliver the range of primary care services available in the community. The level of integration and enhancement required will need to be supported through investment in physical infrastructure, to provide a co-ordinated, user-friendly, inter-dependent range of services in a suitable location and physical environment. The model is dependent on adequate information and communications technology infrastructure and on the ability and willingness of all parties to utilise available technologies. There are also major human resource implications which will dictate the pace of investment. In the short term, reliance will be on existing human resources to get implementation projects up and running, with expansion of numbers weighing in more heavily in the longer term.

Actions

This document outlines the following actions that need to be taken in order to achieve the implementation of the primary care strategy:

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1 A National Primary Care Task Force will be established
2 Individual health boards will prepare needs assessments for primary care teams
3 A Primary Care Human Resource Plan will be produced
4 Primary care teams will be put in place to meet the health and social care needs for a specific population
5 Primary care networks will be developed to support the primary care teams
6 Availability of primary care services out-of-hours will be extended
7 A system of voluntary enrolment will be introduced for primary care users
8 An improved information and communications infrastructure will be provided for primary care teams
9 A system of direct telephone and electronic access to primary care services will be introduced for each health board area
10 There will be greater integration between primary and secondary care
11 Community-based diagnostic centres will be piloted
12 Policy support for the primary care model will be provided by the Department of Health and Children
13 Appropriate administrative arrangements will be put in place to support primary care at local level
14 Investments will be made in extension of GP co-operatives and other specific national initiatives to complement the primary care model
15 Modules of joint training and education of primary care professionals will be developed
16 Continuing professional and personal development programmes will be made available to Primary Care Professionals
17 A framework for quality assurance in primary care will be developed
18 Academic practice and research will be developed
19 Mechanisms for active community involvement in primary care teams will be established
20 Strategy for Nursing and Midwifery in the Community will be developed

Implementation plan

An implementation plan for primary care is outlined in this document. Some of the actions, such as improvements in out-of-hours co-operatives and development of information and communications technology, are independent of but necessary to support the model. Existing infrastructure will be used where possible and the potential of public-private partnerships will be explored.

The primary care model will be implemented on a phased basis in partnership with all the relevant stakeholders. Actions, including timeframes and targets, are set out in this document. The principal actions to be achieved in the short term relate to the development of administrative structures and implementation projects in each health board area and the introduction of services which will have the greatest likelihood of reducing pressure on the hospital system such as home helps and health care assistants. The timetable is contingent on availability of resources, partnership with the service providers and the learning derived from the implementation projects.

While the implementation projects are put in place in the identified locations, primary care in general will be strengthened by increases in the number and range of staffing levels, improved infrastructure, improved organisational arrangements and improved information and communication.

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