State primary care ambitions lack credibility

The primary care strategy of the Health Service Executive (HSE) is admirable in its ambition, but experience on the ground shows that those ambitions are a long way from being reached writes Sara Burke.

Over eight years on from the launch of the primary care strategy, there are 222 teams in place. 90-95 per cent of health care needs can be met by them and they are Brendan Drumm’s pet project. So what do these teams actually do? Do they really exist? And how widespread are they?

The primary care strategy as published in 2001 envisaged these primary care teams to be made up of GPs, nurses, home helps, physiotherapists, occupational therapists, some social workers, speech and language therapists and administrative personnel. Each team serves 8,000 people, is based on a model of teamwork that provides a better service for patients and enables people to get their care in community. A wider primary care network with, pharmacists, dieticians, Community Welfare Officers (CWOs), dentists, chiropodists and psychologists was planned but has not materialised.

According to the HSE, there are 222 primary care teams (PCTs) up and running as of February 2010. The HSE’s definition of a PCT is that they have held one clinical team meeting. Teams hold regular meetings where all the team or representatives of the team get together and discuss a handful of the most complex cases and how their care can be provided. The regularity of the meetings varies between weekly, fortnightly and monthly. 

Of the 222 teams, 150 teams have met more than five times, 70 have met between one and five times and of these about 30 have had just one meeting; presumably, these are the more recently formed PCTs. These multi-disciplinary teams meeting are an indicator of whether the team is up and running and attended by all the relevant personnel.  It is not an ideal measurement perhaps, but at least it is an indicator.

In the 222 teams, there is huge variation in how often and how long teamwork has been taking place and how extensive it is. The HSE has set a target of 530 teams by 2011 and Brendan Drumm said in a memo to senior management just before Christmas that by 2012, "Ireland will have one of the best primary care infrastructures in the world". By any reckoning, that is an ambitious statement.

So are the 222 teams an accurate reflection of what is happening around the country, or is it just spin?

If you use the HSE definition of just one clinical team meeting then it is accurate, but if you think about it as how it was outlined in the strategy its not. However, even in some of these areas not all GPs are cooperating and GPs are central to an effective primary care service. And is just one meeting a sufficient demonstration of a team?

So question marks hang over Drumm’s target of 530 teams. This plan is almost a decade old and we have just 40 per cent of the total number of teams operating. So far, most of the country still do not have primary care teams. While 530 by the end of next year is ambitious, there is a renewed emphasis to get them all up and running in the HSE. 

No matter how much will there is within HSE management, however, it will be even harder to achieve these ambitions in the current environment of a shrinking work force, the recruitment embargo and a declining budget. As well as this, the unions are currently not cooperating with ‘change’ and will not fill vacancies as part of their industrial action since the pay cuts introduced in budget in December 2009.

Some of the teams are up and running in the originally envisaged HSE owned and built state of the art primary care centres. In these places there are very obvious benefits.

Previously, all the health professionals worked in silos. Now they work together to the benefit of the patients. And while they may only discuss the most complex cases in official team meetings, the fact that they are located in the same purpose built building and see each other day in day out means they can provide a better, more seamless service in response to local needs.

Only about a dozen of these teams are in new state of the art primary care centres but many of the HSE staff are all working in the same health centres and the GPs down the road or near by. The location of the teams is an area of contention. The HSE says it does not matter where you are located, it is the method of working that matters. However, the Irish College of General Practitioners say that if you are not working from the same building then you are a ‘virtual’ team and that team working is not so effective.

GPs are self employed business people, while the rest of the teams are HSE staff, so there is no compulsion for the GPs to participate in primary care teams. And it does seem that there are different experiences in different places. As GPs are self employed they don’t have to work as part of a team or attend meetings. 

Some GPs say they cannot see any benefit of it. However, I think the majority who have experienced it quickly see the benefit to patients despite the initial culture shock.

In August 2008, the HSE carried out research on links btw GPs and public health nurses in areas without PCTs. Their findings are extraordinary. They discovered that 20 per cent of GPs and public health nurses had never had face to face contact and that 56 per cent of GPs and 77 per cent of public health nurses did not have each others mobile phone number.

As well as this, 97 per cent of GPs and 81 per cent of public health nurses had no working email address for each other.  And although 45 per cent of GPs and public health nurses were in weekly phone contact, as many as four per cent reported contact on less than an annual basis.

So if nothing else, the primary care teams get the professionals working together and in doing so they provide a better service for the patients, keeping them at home and out of hospital with an increased quality of life. Anyone can access them if you have a team in your area and by 2011, they are meant to be nationwide. But how much does it cost? 

Well, like most of our health system, the answer here is not clear cut and varies greatly from place to place. In some areas, all services are free no matter whether you have a medical card or not and access is based on clinical need. In others, you have to pay if you do not have a medical card. However, some services like public health nursing and home helps are universal although provision varies greatly from area to area.  For me, this is one of the biggest problems with health provision in Ireland. People just do not know who is entitled to what, and it is pot luck depending on where you live.

There is currently a group reviewing the issue of eligibility in the Department of Health. The department has been reviewing this for years now but apparently they will be making recommendations to government this year, which will require detailed legislation. This will probably take until next year to go through. All of this is taking place in the context of the Resource Allocation Working Group, which is due to report to government by the end of April 2010.

In my opinion, until there is clarity as to what you are entitled to and how you can get it, the public will remain sceptical. Until people see these enhanced primary care services, a credibility gap remains between what Brendan Drumm and Mary Harney are saying and what people experience on the ground.

Sara welcomes any thoughts on this or experiences of primary care teams. She can be contacted using the comments box below or via her website.