PART 2

Primary care model - a description

Introduction

The considerations set out in Part 1 of this document point to the need for the development of community-based health and personal social services in Ireland. However, in doing this, equal attention needs to be given to how the various services and individual professionals operate so that patients or clients can easily access the services or range of services they require. Experience elsewhere points to greater effectiveness from an integrated team-based approach. For these reasons, the Government has decided that the development of primary care, based on a team approach, will be central to the planning and delivery of health and personal social services for the future. This section outlines an expansion of primary care so that it becomes the main setting for delivery of health and personal social services and a key component of health education, early intervention and disease prevention.

Primary care should be the first point of contact that people have with the health and personal social services. The role of the primary care services as the provider of the majority of all care requirements and the gatekeeper of specialist services will be strengthened. This will involve a team-based approach to service provision, which will help to build capacity in primary care.

The Irish health system places a considerable reliance on hospital care as illustrated in Figure 1. This diagram shows a series of squares, becoming progressively smaller. The outer square represents the whole population in a given time period, including those who are healthy. The next layer represents those who have some health issues but do not seek professional assistance and very often provide care for themselves. The grey zone represents those who seek assistance from GPs, nurses and other primary care providers, while those who require secondary care are represented by the very small black square. This illustrates that only a very small proportion of those who seek care require secondary hospital or specialist care. The dark arrows represent forces such as recent trends towards increased specialisation or over-reliance of people on professional help rather than self care. The primary care model can provide a force (dotted arrows) which runs counter to this and can therefore move care, where appropriate, from secondary to primary level, from primary level to self care (by empowering people), and from self care to no care requirement (through illness prevention and health promotion). In Ireland, it is estimated that there are 15-16 million consultations in general practice while approximately 1.9 million consultations take place in out-patient departments each year.

Figure 1: Relationship between primary care and other care levels

Diagram showing relationship between different care levels

Model of primary care

This section describes the proposals for primary care. It outlines the model under a number of relevant headings, and provides an overview of the service as envisaged in the Health Strategy.

Primary care team

Primary care will be centred on the needs of individuals and groups of people and will match their needs with the competencies required to meet them. Some of the essential competencies will include assessment, diagnosis, therapy, nursing, midwifery, prevention, health education, counselling, administration, management, social services, referral and rehabilitation.

A group of primary care providers will come together to form an inter-disciplinary team, known as the primary care team. These teams will serve small population groups of approximately 3,000-7,000 people, depending on whether a region is rural or urban. Among other factors, the number and ratio of team members will depend on needs assessment, location and population size. In the long term, approximately 600-1,000 primary care teams will be required nationally, based on a population of 3.8 million. Teams will include appropriate levels of administrative support. A wider network of additional professionals will be formed to provide the therapy services required by a number of core primary care teams. Figure 2 illustrates the proposed membership and interaction between the core primary care team and the wider network of primary care providers. The diagram is for illustrative purposes only. In practice, there may be more or less than three primary care teams working with the wider primary care network. The ultimate arrangement will be determined by needs assessment and geographical spread of the enrolled population.

Figure 2: Primary care team and primary care network

diagram showing components of the primary care team

The proposed membership of the primary care team is set out in Table 1. The numbers of various team members presented are for illustrative purposes only and will need to be considered in depth during the implementation process. The nurse/midwife functions would include advanced nurse practitioner, clinical nurse specialist, public health nursing, midwifery, mental health, practice nurse and general nursing competencies. The optimal number and ratio of physiotherapists, occupational therapists and social workers required for the primary care team will depend on needs assessment and the geographic location of the team. Some therapists may work with more than one core primary care team. This will be determined in the implementation phase.

Table 1: Proposed membership of primary care team

Primary care team

Number envisaged*

General practitioner
4.0
Health care assistant
3.0
Home helps
3.0
Nurse/midwife
5.0
Occupational therapist
0.5 – 1.0*
Physiotherapist
0.5 – 1.0*
Social worker
0.5 – 1.0*
Receptionist/
clerical officer
4.0
Administrator
1.0

*For the purpose of calculations, the average population size served by the primary care team is taken as 5,000. Some eight additional whole-time equivalents (WTEs) will be required to provide extended-hours care by the primary care team and 24-hour GP and nursing/midwifery services.

*to be assessed

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Primary care network

It is envisaged that a wider network of health and social care professionals will be formed who will work with a number of primary care teams. Each primary care team will have access to a range of health and social care professionals who will provide services for members of their enrolled population group. Members of the network will work with more than one primary care team. Formal communications processes will be established between the core primary care team and the wider network of professionals. Named members of the primary care network will be designated to work with specific primary care teams. The proposed membership of the wider network is set out in Table 2 below.

Table 2: Proposed membership of primary care network

Chiropodist
Community pharmacist
Community welfare officer
Dentist
Dietician
Psychologist
Speech and language therapist

 

Capacity of primary care team

The inter-disciplinary team approach will help to develop the capacity of services at primary care level. The wide skill mix within the team will allow a more appropriate distribution of workload between members of the team. This will allow each team member to work to his or her maximum professional capacity. It will also allow team members to spend more time on areas such as preventive work and continuing professional development. Additionally, this will allow support to be given to inter-referral between primary care providers such as GPs which can also enhance the capacity of primary care.

This approach to primary care will facilitate communication between team members which will greatly reduce the time currently spent trying to contact other primary care providers. The team structure will provide support to all its members. To reach its full potential, however, significant investment in education and training will be required.

The provision of a wide range of services in this way will allow a higher percentage of patients to be cared for in the community. The increased provision of home helps, for example, should enable patients to stay at home with support and prevent crisis hospital admissions. The provision of health care assistants and occupational therapists in the community should allow patients to be discharged earlier from hospital.

Information and communications technology

Appropriate electronic communications and electronic record systems are central to the operation of both the primary care team and the wider network of professionals. There will be considerable investment in information and communications technology infrastructure. This will include the development of an electronic health record based on a unique client number. Patient information will remain confidential and will only be available to those team members who need it.

Many of the issues relating to information and communications technology will be addressed in the forthcoming National Health Information Strategy and in the on-going General Practice Information Technology project.

Enrolment with primary care team

GPs and other professionals keep records of patients who utilise their services. However, it is recognised that these systems may be inadequate for key functions such as comprehensive call and recall as required for screening and immunisation. In this regard, practice registers are an essential component of high-quality primary care.

The Health Strategy 2001 envisages a system whereby people are invited to actively enrol. All individuals will be encouraged to enrol with one primary care team, and with a particular GP within the team. Where appropriate for an individual’s needs, a key worker will be identified.

Enrolment will be voluntary. The benefits of enrolling with a team will include better continuity of care, improved co-ordination of services, and more attention to preventive services. Enrolment will not reduce people’s choice of provider and patients will be free to seek care wherever they wish. Individual members of a family will be able to enrol with different teams or with different doctors within the team. The system will also allow people to change their nominated team or doctor.

The primary care model in action ...

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Delivering integrated family care

Mary is 37 years old and lives with her husband Niall (42 years), a casual labourer, and four children, Paul (10 years), Mairéad (6 years) and Seán and Conor (twins of 15 months). Mary has come to the primary care centre with Seán and Conor for their MMR vaccination. At the visit she appears very stressed and expresses concerns to the nurse that Conor has not started walking yet. Patricia, the nurse, spends some time with Mary, listening to her concerns and reassuring her about Conor’s developmental progress.

In the course of the consultation she discovers that Niall has been drinking heavily, leading to worsening financial problems, and that the oldest child Paul has started to wet the bed and has become disruptive in school. Patricia arranges to see Paul a few more times in keeping with the practice protocol on enuresis and provides Mary with information on the local branch of Al-Anon. An appointment is arranged for Mary and her husband with the community welfare officer for the following week to assist with accessing financial benefits.

Access to primary care team

Individuals will be able to self-refer to any given member of the primary care team or network as appropriate. There will also be a system of triage and referral at the point of access available for those who wish to use it. This will ensure that people can be linked with the most appropriate professional for their needs.

Access to primary care services, particularly out-of-hours, will be improved for all, following the introduction of this new model of primary care. Services will be more flexible to accommodate those who work during the day. This system will build on the strengths of the current co-operative model for GPs. The hours during which all of the basic primary care services are provided will be increased, with a number of essential services on a 24-hour basis. An improved range of services will also be provided at weekends.

Eligibility

The broad issue of eligibility is addressed in the Health Strategy (2001) document. The main actions outlined are as follows:

Broad focus for primary care services

The primary care team will work with local populations and other agencies to identify health and social needs. It will also provide appropriate responses including the range of general medical services in addition to the generalist aspects of services for mental health, elderly care, drug misuse, disabilities, family support and child health. This will necessitate inclusion of personal social services staff on the teams.

Population health services will be strengthened and expanded to ensure widespread uptake of initiatives such as screening, immunisation and early intervention. Primary care teams will be facilitated and funded to develop and expand cross-sectoral activities which can promote and protect the health of people and families enrolled with them through, for example, school and community-based health education, counselling and classes, links to local area action plans to provide integrated information and services, as well as links to community development projects.

Broadening the focus of primary care means the re-allocation of responsibility to the primary care team for services which are currently provided in specialist care settings but which may require less extensive specialist input. Examples include care of those with diabetes mellitus, high blood pressure, routine ante-natal and post-natal care, child health surveillance and generalist mental health services.

The primary care model in action ...

Delivering a person-centred inter-disciplinary preventive service

John, a 45-year-old businessman, is worried about a dark mole on his arm and he decides to telephone his local primary care centre. He looks up the web site from his office and calls to arrange an appointment.

Ann, the receptionist, sees from John’s electronic record that he was invited for a ‘high-risk cardiovascular assessment’ earlier in the year but did not come in. She suggests that when John is in this evening with the GP he could also meet with the nurse and have his assessment done. John thinks this is a great idea as he was away on business for the last appointment and has been too busy ever since.

Órla, the GP, removes the mole in the surgery and sends it to the local hospital for histological examination. She feels that it is not malignant and reassures him on that basis. This is confirmed when she receives the report electronically from the hospital five days later.

Peter, the nurse, meets with John and in the course of the consultation John discloses that he smokes 20-25 cigarettes a day and that he has tried to give up in the past, with little success. Peter arranges a prescription for nicotine replacement therapy and invites him along to the stop-smoking support group that meets in the primary care centre on Thursday evenings.

Co-ordination of primary care and specialist services

The primary care team will liaise with specialist teams in the community to improve integration of care. Community-based specialist teams are already in existence in the community for many specific care groups.

The primary care team will integrate with these community-based specialist teams in ways similar to how the primary care team will integrate with the specialist institutional services, e.g. acute hospitals. The benefit of this from the perspective of users is that they are facilitated, through a single point of contact, in accessing whatever specialist services they require. Examples of specialist teams based in the community include:

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Figure 3: Overview of primary care and specialist services

diagram showing how primary care teams fit in with specialist services

Primary care teams have the potential to deliver much of the care currently provided by specialist services. However, realising this potential will require better integration between secondary and primary care services. The purpose of such integration is to provide more seamless care for individuals, families and groups and to ensure that the two sectors operate together as a whole rather than two separate entities. Figure 3 is provided to assist in understanding the complexity of services available in the community, particularly the connection between the generalist primary care team and the wider primary care network and specialist services.

Primary care teams will have direct access to appropriate hospital-based diagnostic services based on local protocols, which can support earlier intervention and better on-going care for individuals. In addition, community-based regional diagnostic centres to support primary care and care in the community will be piloted and evaluated. There will also be improved shared care arrangements for patients with conditions such as diabetes and asthma, to enable them to be managed more effectively and by a broader range of professionals in the community.

Local arrangements will also be put in place covering referral protocols, discharge plans, individual care plans, integrated care pathways and shared care arrangements. Some of these developments will require certain team members to act as key workers for individuals with complex chronic care needs.

The primary care model in action...

Interface between primary and secondary care
Jane is worried about how she will cope now that her mother has just been admitted to hospital. Bridget (79 years) had a mild stroke from which she still has some weakness in her left hand and arthritis in her left hip. Although frail prior to the stroke she had lived independently in her own home.

The day following admission the hospital discharge nurse contacts the local primary care team administrator to plan in advance for Bridget’s discharge. Liam, the occupational therapist, calls Jane to arrange a time convenient to do a needs assessment of the home care environment. Following the assessment he convenes a meeting with Jane, together with the nurse, GP, physiotherapist, social worker and hospital discharge nurse to draw up an individual care plan aimed at maintaining her mother in her own home. The hospital discharge nurse attends the meeting. The meeting concludes by agreeing that the home help and health care assistant will visit Bridget daily and the physiotherapist will visit every second day.

Jane leaves the meeting relieved that with a home care plan for her mother in place, the primary care team will be able to provide her with the support that she needs to allow her mother to come home. She also feels that her mother, with access to respite care, might be able to avoid admission to hospital in the future and may be able to be back in her own home sooner.

Location of primary care teams

Though not essential, primary care team members should ideally be located on the same site or in very close proximity. The exact location will reflect local circumstances and the availability of appropriate pre-existing facilities. The role of public-private partnerships and other options will be explored as an alternative when premises are being sought to house the primary care teams.

Facilities for some of the professionals operating in the wider network should be made available in the primary care premises. The nature of work carried out by some team members, such as public health nurses, home helps and health care assistants, dictates that a number of services will be delivered to people in a home setting. The goal should be to establish lines of communication and mechanisms for integration that lead to a more efficient and seamless service for the individual and the community.

This will have particular implications for some members of the wider network, such as dentists, psychologists and community pharmacists who, while continuing to operate as independent private practitioners, will need to develop stronger linkages to the primary care team. For all other team members, the goal will be to ensure that they operate from premises located in a convenient and accessible location for the population which the primary care network serves.

Advantages for consumers and patients

One of the principal advantages for consumers and patients will be improved access to primary care services, particularly out-of-hours. The range of services provided in a primary care setting will also be increased, especially in areas such as prevention, health promotion and rehabilitation. A variety of supports will be provided, e.g. health care assistants to support patients in the home, and thus reduce the need for crisis hospital admissions. Greater availability of GPs will allow for increased consultation time to the benefit of both patient and doctor.

Many primary care services will be provided in a 'one stop shop'setting, which means that a patient or family can access a number of health care providers in the one centre. Patients who enrol with a particular team or doctor and wish to change will be facilitated in doing so. From an individual's point of view the system will become simpler and more supportive. A clarified and simplified system of eligibility will be provided so that people know what services they are entitled to and how they can access these services. Finally, information about health and the health services will be easily accessible via a single telephone and internet access point.

Advantages for professionals

Advantages for professionals involved in a primary care team will include improved access to other team members. Direct access to diagnostic facilities, secondary care services, and infrastructural and information technology supports will also be improved upon.

The introduction of a properly resourced primary care team with its skill mix will ensure that many health professionals will have more time to engage in preventive activities and continuous personal and professional development. With the introduction of extended hours, working hours for many team members will become more flexible. This model of primary care will also mean less stress and improved morale for the health care professionals involved. Career structures will be enhanced for all members of the primary care team. Research and development opportunities will also be improved.

Advantages for the health system

Primary care, planned and organised on this basis, could lessen the current reliance on specialist services and the hospital system (particularly accident and emergency and out-patient services) and, based on available evidence, would have the potential to reduce the requirement for specialist services, reduce hospitalisation rates, reduce lengths of stay for those who are hospitalised, promote more rational prescribing, and improve efficiency.

The primary care model in action ...

Delivering a high-quality primary care service

In the course of setting up the primary care centre, an audit was carried out which identified a number of people with a history of heart disease who were not taking aspirin. Pauline (67 years) was invited to attend the primary care centre to review her treatment in light of this. She has a history of high blood pressure and had a heart attack two years ago but is doing well since. Dermot, the GP, explains that, in light of her past history, aspirin would be of benefit to her and he adds it to her regular quarterly prescription.

When Pauline collects her prescription, the community pharmacist who has received electronic notification of the new prescription explains the effects that aspirin might have when taken along with her current medication. Pauline meets a friend for coffee and tells her about the thorough service at the primary care centre.

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