Primary care plays a central role in the provision of health care services in Ireland, involving not only access to GPs but also to a broad range of community-based services including nursing, social work, chiropodists, midwives, physiotherapists, occupational therapists, speech and language therapists, child health care, dental care and ophthalmic care services.
Primary care services can be traced back to the Irish Dispensary System set up in 1851. The Poor Relief (Ireland) Act of 1851 placed a duty on Irish Poor Law Commissioners to ensure that local health care dispensaries were set up.
Under this system the poor could receive treatment from a state-employed physician at their local dispensary. These physicians could then treat the rest of the community on a private basis. The distinction in service provision between the poor and non-poor was highly visible, but moves towards a United Kingdom-style NHS or Bismarckian comprehensive social insurance system never materialized in Ireland – in part due to the influence of the Catholic Church, which felt that such initiatives were in conflict with the principle of individual responsibility, and might be seen to promote socialism. Thus, the dispensary system remained in place with only some limited change for a period of over 100 years, until the Health Act of 1970, when the current system of primary care was established, involving the provision of the General Medical Services (GMS) Card. The new GMS system allowed, for the first time, some choice of primary care doctors for the whole population, although this still meant that only around one third of the population (who qualified for Medical Card/Category I status) would have free access to General Practitioner (GP) services. Other schemes were set up to cover individuals with chronic illness, while a cap was set on the level of out-of-pocket payments in relation to pharmaceutical expenditure through the Drugs Payment Scheme.
At the end of 2006 there were more than 2.91 million people registered as being eligible to benefit from either the GMS scheme or related schemes. A total of 1 221 695 people were eligible for the GMS scheme (that is, holders of Medical Cards), which represents 28.85% of the total population; 1 525 767 people (36.03% of the population) are covered under the Drugs Payment Scheme; and 106 307 (2.51% of the population) are covered by the Long-Term Illness Scheme. More than 95% used either the GP, Pharmaceutical, Dental or Opthalmic services that were provided by 5811 health professionals under the GMS system.
However, with growing economic prosperity the proportion of individuals qualifying for Category I status has declined in recent years. Recognizing that the charges levied by GPs for a consultation (typically €60–80) might act as an inappropriate deterrent to service use, and mindful of the increasing number of individuals choosing to present at hospital Accident & Emergency (A&E) departments (where consultation charges are lower), in 2005 a GP Visit Card was introduced to supplement the Medical Card. This new card allows individuals with modest incomes just above the cut-off point for Medical Cards to qualify for free GP services; 51 760 individuals (1.22% of the population) held GP Visit Cards at the end of 2006.
There has been much debate on the primary health care system in recent years, with some commentators arguing that the primary care system has been somewhat neglected in comparison to the hospital sector. However, the importance of primary care is clear in national health policy. The recognition that primary care services needed to be reformed and strengthened so that they would be capable of dealing with “90–95% of all health and personal service needs” formed a cornerstone of the blueprint of current reforms set out in Primary care: A new direction. Significant reform within the primary care sector is under way and is discussed later in this chapter.
General practitioner services
GPs usually provide the first point of contact for health care, followed by referral to specialist physicians, if necessary, who operate largely in hospital settings. GPs, therefore, are regarded as the “gatekeepers” to secondary care. It is possible to directly access secondary care, but a standard fee (€60) is charged for a non-emergency visit to an A&E department in acute public hospitals. Consultations are free if the individual has a letter of referral from their GP or is a Medical Card holder. The primary purpose of this charge is not to raise additional funding but rather to discourage inappropriate attendance at A&E departments by those with conditions which could be easily treated within primary care. (In recent years, however, the increase in charges levied by GPs has reduced the impact of this co-payment as a deterrent to the use of A&E services.) GPs are self-employed, usually working in single-handed practices or in some form of joint practice – or cooperative arrangement – in which, for instance, out-of-hours work might be shared. In 2001 approximately 51% of all GPs worked in single-handed practices, 26% in partnerships comprising two individuals, 15% in partnerships comprising three individuals and 8% in practices of four or more partners. While there are some GPs who work exclusively either in the public or private sector, the majority treat both private and public patients. Those providing public sector services enter into a contractual agreement with the National Primary Care Reimbursement Board. Fees are based primarily on weighted capitation, plus additional payments for special services. GPs working solely in the private sector may still have a contract with the HSE to provide publicly funded care for their private patients when they reach the age of 70 (and thus qualify for a Medical Card automatically, irrespective of income level) or if they have patients who have been infected with hepatitis C.
More generally, most GPs provide public maternity, infant and vaccination services on behalf of the local Primary, Community and Continuing Care (PCCC) Directorate office of the Health Service Executive (HSE). Category I (Medical Card) patients must register with a specific GP of their choice (hence the scheme is sometimes known as the Choice of Doctor scheme), while all others who pay privately for services are free to seek health care services from any GP.
Other primary care services
In the former Eastern Regional Health Authority (ERHA) area alone, in 2004 it was estimated that nearly 800 GPs and 1000 nurses would provide primary care services, and that over 40 000 contacts would be made with GP out-of-hours cooperatives. A total of 5000 people would also receive orthodontic treatment; 42 000 schoolchildren would receive dental treatment; and 94 000 treatments would be carried out under community ophthalmic schemes. All the Health Boards were developing primary care services and introducing innovations in line with the National Health Strategy and other documentation.
In each region of the HSE, there are a number of specific strategy projects, including those related to cardiovascular health, such as smoking cessation and Cardio-Pulmonary Resuscitation (CPR) training. Vocational training schemes may be provided for health care professionals, while increasing use is being made of ICT in primary care at local level – for instance, through the implementation of secure GP e-mail services and the further rollout of Public Health Nurse mobile computing.
Community nursing services
Community nursing services were previously provided by all of the Health Boards, and now by the HSE. These include not only general nurses but also specialists working in public health, geriatrics, mental health and midwifery. Home helps and health care assistants who provide assistance and care for people within their own homes may also be provided. The majority of GP practices have at least one practice nurse.
Ongoing reform: implementation of the Primary Care Strategy
Ongoing reforms aim to better organize and support GP services so that the system may support a wider and more integrated role within the health care system. Primary care: A new direction (2001) set out the proposed reforms, together with an implementation timetable and plan. In essence, the plan proposed that an interdisciplinary team approach be adopted for the delivery of primary care services. This would be phased in, building on the existing infrastructure, over a 10-year period. At the time of writing, greater emphasis is being placed on health promotion, prevention, early rehabilitation and personal social services, in addition to the focus on diagnosis and treatment.
Another objective is to encourage public–private partnerships, where practical. The National Health Strategy noted that: 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.
While the report recognized the crucial role played by primary care professionals in delivering excellent primary care services and in ensuring public satisfaction, it noted this was achieved despite not having an effective infrastructure; one key limitation was the lack of availability of many professional groups and limited out-of-hours access to some services, increasing the burden on secondary care. Key challenges identified in the 2001 report included:
- poorly developed primary care infrastructure and capacity;
- current system fragmentation from the users’ perspective;
- limited opportunities for user participation in service planning and delivery;
- emphasis on diagnosis and treatment with weak capacity for prevention and rehabilitation;
- no full realization of the potential to reduce pressure on secondary care;
- secondary care is providing many services which are more appropriate to primary care;
- current system is oriented around the needs of providers rather than users;
- underdeveloped out-of-hours services;
- limited availability of many professional groups;
- professional isolation;
- limited teamwork taking place;
- inadequate communication between professionals and sectors;
- lack of quality assurance framework; and
- limited information from primary care for planning, development and evaluation.
The policy response to the weaknesses identified in 2001 was to develop Primary Care Teams. Each one, effectively providing a “one-stop shop”, would serve a population of between 3000 and 7000 people depending on whether it is located in an urban or rural area. Nationally, between 600 and 1000 Primary Care Teams are required. Essential skills within the teams are to include assessment, diagnosis, occupational and physiotherapy, nursing, midwifery, prevention, home help, health education, counselling, administration, management, social services, referral and rehabilitation. In addition to these core teams, a network of more specialist professionals would provide services to the new teams. These specialists may include chiropodists, community welfare officers, community pharmacists, dentists, dieticians, psychologists, and speech and language therapists. As well as investment in education and training, electronic health records were to be developed as part of the General Practice Information Technology Project, in order to improve communication and the flow of information. To implement the strategy, individuals would be actively invited to enrol with a practice and primary care centres would be charged with working with other local population groups and agencies to identify local needs. Additional funding would be provided for screening, immunization, early-intervention services and cross-sectoral interventions, such as those in schools or community education projects. Links with secondary care would also be strengthened, discharge plans would be prepared for those leaving the secondary care sector and individual care plans would be formulated, along with integrated care pathways and shared-care arrangements. A single-point, 24-hour access telephone and internet health information, advice and triage system also would be set up.
Generally, the strategy was welcomed by professional groups, including the Irish College of General Practitioners (ICGP). A National Primary Care Taskforce was set up to oversee the implementation of the strategy, reporting to a wider National Primary Care Steering Group, chaired by Professor Ivan Perry and containing representatives from the Health Boards, professions and expert groups. Specifically, the Steering Group was charged by the Minister of Health and Children (MoHC) with:
- defining a broad set of primary care services to be delivered by Primary Care Teams;
- developing quality systems, including the development of performance indicators, in primary care service delivery;
- identifying models and locations for the establishment of academic centres of primary care as a source of policy and practice advice to the DoHC, Health Boards and other bodies, as appropriate; and
- developing a national framework for integration within primary care and between primary and secondary care.
The new primary care provision model emerging from the developments outlined above has been subject to consultation, led by the Primary Care Steering Group, and a series of Strengths, Weaknesses, Opportunities and Threats (SWOT) analyses. One key concern has been whether it will be possible to train, recruit and retain all the additional professional staff required. Ensuring the availability of a balanced Primary Care Team will only prove feasible if adequate staff are available in the required disciplines and on an appropriate geographic basis. Another challenge to be faced, in the absence of strong incentives, is to persuade primary care professionals to voluntarily “opt in’” to the new Strategy. Considering that about half of the GPs in Ireland operate in singlehanded practices at the time of writing, it is to be reasonably expected that it will require more than a government commitment to an interdisciplinary, team-based approach to support and advance this objective. Certainly, the continued support of a range of stakeholders is crucial, including the ICGP, which has consistently argued that primary care has been neglected by successive governments in comparison to hospital care.
Different models of working in partnerships have been set up and evaluated, with a view to establishing approaches countrywide. A total of 10 implementation projects, one in each (former) Health Board area, were approved in October 2002 in order to provide an opportunity to test the new model on the ground. Three community-based diagnostic centres were also piloted and evaluated. Additional revenue and capital funding was provided to support the development of these projects. The initial infrastructure costs associated with setting up the pilot Primary Care Teams were €2.5 million per team or a total cost of €1270 million (at 2001 prices). In addition, there would be one-off IT costs of €50 million and annual costs of €10 million at the end of the 10-year period. It is estimated that an additional 500 GPs and 2000 nurses/midwives would be required, together with significant increases in representation of other professional groups. Staffing costs at the end of the 10-year period will be €484 million per annum.
First progress report on implementation of the strategy
The National Primary Care Strategy Steering Group produced its first report on the implementation of the strategy in July 2004. The Steering Group, while recognizing that the current health service reform programme “provided an opportunity to mainstream primary care within the health system as a whole”, noted that the momentum for reform in the sector generated by the Primary Care Policy documents do mention the benefits to professionals of working in teams and avoiding isolation, but do not appear to provide other more formal incentive mechanisms, although GPs may become budget holders similar to the old Primary Care Groups in England. Strategy may become dissipated in the wider process. In particular, there was concern among members of the Steering Group that in discussions regarding acute hospital services reform (the Hanly Report) the pivotal role of primary care received insufficient attention. Clearly, it is more difficult to reduce pressure on secondary care services or develop a sustainable “hub and spoke” model of hospital care without an adequately resourced multidisciplinary primary care infrastructure. The group called for “substantial and sustained investment in the years ahead to provide the additional capacity to implement the strategy on a system-wide basis”.
The Steering Group members were of the opinion that eligibility for primary health care services still excluded too many families on modest incomes, aggravating health inequalities, and needed to be clarified further, particularly given the role for public-private partnerships in the provision of capital for primary care projects. In the long term, they felt that there should be an aspiration for universal free access to primary care services in Ireland.
Among the report’s other recommendations were that a Primary Care Division be established within the DoHC and a function established within the new HSE to drive forward implementation of the Primary Care Strategy.
Following the publication of the Steering Group’s report, the DoHC introduced measures in 2005 at a cost of €60 million to increase the number of individuals eligible for Medical Cards, as well as introducing a new GP Visit Card for those on slightly higher incomes. As part of the restructuring of the DoHC, there is now a Primary Care and Social Inclusion Public Health Division and the internal structures of the HSE have also been reformed. The HSE were committed to introducing a major change management programme to better re-orientate primary care services to the goals of the Primary Care Strategy and to disseminate and transfer knowledge and learning from the 10 existing multidisciplinary Primary Care Teams. Common standards on out of hours services, better coordination and increased integration between services were emphasized. By the end of 2005, out-of-hours cooperatives were available in at least part of 25 of the 26 counties in the country, and the introduction of more out-of-hours services and expanded palliative care facilities have also been promised.
Speaking in the House of Representatives (Dáil) in March 2006, the Minister of Health again reaffirmed the Government’s commitment to the principles contained within the Primary Care Strategy, pledging additional financial support of €16 million, of which €10 million was to support the establishment of 75–100 Primary Care Teams nationally. This, she estimated, would enable the provision of 300 additional front-line personnel to work alongside GPs to provide integrated and accessible services in the community. A further €4 million was provided for the establishment of additional GP training places and €2 million to enhance GP out-of-hours cooperatives.
By early 2008, 80 teams were in place, with the intention of increasing this to 530 teams in 2010. Each team will serve between 8000 and 10 000 people (larger than originally envisaged in the 2001 Strategy).
Equity of access to primary care
An equity concern within the Irish health care system has been access to primary care services. Until 2005 these services were available free of charge to patients with Medical Cards, as well as some other (limited) specific population groups, but for more than two thirds of the population charges applied, set independently by GPs. Historically, within the health and political systems there has been much resistance to the introduction of a free, universal primary care system, even for children, although the issue of the extension of medical care coverage has been on the political agenda in the last few years, with the Labour Party proposing universal access; Fine Gael proposing an extension of Medical Card coverage; and the National Primary Care Steering Group also being in favour, in the long term, of free universal coverage to help implement the new Primary Care Strategy. These concerns have been particularly relevant within the context of the declining proportion of the population entitled to Medical Cards in recent years. The two increases in the income threshold for Medical Card entitlement in 2005, as well as the introduction of the new GP Visit Card was the Government’s response to these concerns.
The costs to individuals not qualifying for Medical Cards can be significant, especially for those just above the qualifying income threshold. In 2002 it was estimated that one visit to a family doctor cost one third of the weekly income of an individual just above this threshold. Another more recent analysis suggests – after controlling for socioeconomic and health status – that Medical Card holders are significantly more likely to visit their GPs, and also visit their GPs more frequently, than those without Medical Cards. This may reflect overconsumption of primary care services on the part of Medical Card holders, but also may be evidence of the under-consumption of services for the two thirds of the population faced with financial barriers to access to primary care services. This same study reported that those with private health insurance were also more likely to visit GPs than those without insurance, which may indicate that the population group that may be most affected are those above the Medical Card threshold, but for whom private insurance is either not affordable or not thought to be necessary. This issue of equity of opportunity to access primary care is crucial to the success of a primary care-driven health system, as envisaged in the Health Strategy, and is one that can have significant resource implications for the utilization of secondary care resources.
Until very recently, voluntary health insurance packages in Ireland provided only very limited coverage for primary care, usually subject to a deductible of several hundred euros. A wider range of packages is now available from all three principal insurers, including those that do not include the payment of a deductible. Future analysis will be required to examine the impact on utilization of primary care services in terms of both enhanced insurance packages and the availability of the GP Visit Card. A different equity concern is that of the location of primary care practices.
At the time of writing the capitation fee schedule pays a rate between three and five times higher for those over 70 years of age who received a Medical Card since 2001, compared with those already in possession of a Medical Card prior to that year. This potentially could have some influence on the location of GP practices, that is, by acting as an incentive for practices to be located in more affluent locations. At the time of writing, however, there is insufficient evidence to determine whether this is the case. One survey conducted by the Centre for Insurance Studies, University College Dublin, reported that one third of 1000 individuals questioned said that their decision to visit an A&E department was influenced by GP availability, while 28% reported that they made their decision because of the lower charges for an A&E visit (without a referral), compared with those for consulting a GP.
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