FURTHER WRITTEN SUBMISSION BY THE IRISH MEDICAL ORGANISATION IN
RESPECT OF THE ROLE OF COMMUNITY HEALTH DOCTORS IN PRIMARY CARE
Outline of importance of BCG vaccine and the incidence of Tuberculosis. (Deputy James
Reilly)
In 2006 there were 465 cases of TB notified in Ireland, giving a national crude incidence
rate of 11.0 per 100,000. This has increased slightly from the rates recorded between 2000
and 2005, which ranged from 9.7 to 10.6 per 100,000. However this is lower than the rates
between 1991 and 1999 and lower than the EU /Western Europe overall notification rate
of 17.4 per 100,000.
BCG is given to protect against the most severe forms of TB (i.e. TB meningitis and
miliary TB), especially in infants and young children. One case of TB meningitis is
prevented in children aged less than five years for every 12,500 to 16,667 infant BCG
vaccinations given. Combining the results of the evidence gives BCG an efficacy of up to
80% in preventing TB. The protection lasts between 15 and 20 years. The efficacy is
probably lower against Multi Drug Resistant TB (MDR-TB)1.
Ireland does not yet meet all of the International Union Against Tuberculosis and Lung
Disease (IUATLD) criteria for discontinuation of the national (neonatal) BCG vaccination
programme2.
One of the criteria states that the average annual notification rate of TB meningitis in
children under five years of age should be less than one case per ten million general
population over the previous five years. Ireland does not currently meet this criterion.
Between 2001 and 2006 there were four cases of TB meningitis in children under five years
(one in 2006, two in 2003 and one in 2002). Of the four cases only one child had been
vaccinated.
The IMO acknowledges that there have been gaps in the delivery of this programme in
some parts of the country.
The delivery of this programme is dependent on the
availability of an adequate number of medical, nursing, and administrative personnel and
IT support, suitable clinical facilities, and a reliable consistent supply of the vaccine.
IMO involved in the inspection of private nursing homes. How does it see its future in how
the HSE’s nursing homes will be inspected, given that we do not like the principle of the
HSE investigating or inspecting itself?
How does the IMO view its role in the HIQA? Will it interact with HIQA or will that
involve a different set of doctors? (Deputy James Reilly)
Community health doctors welcome the introduction of an independent inspection
process. As we understand it, HIQA will have responsibility for inspecting and registering
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2.
Guidelines on the Prevention and Control of Tuberculosis in Ireland (2008) National TB
Advisory Committee: Draft for Consultation July 4th 2008
HPSC (2008) Epidemiology if Tuberculosis in Ireland (Appendix 3)
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all homes, both private and HSE. The HSE will have to have local governance
arrangements to ensure that it is happy with the standards of any facility that it places
patients/residents in.
The information available from HIQA indicates that they will base their 3 yearly
registration of homes on their risk assessment. It is likely that the number of statutory
inspections carried out by HIQA will be less frequent than is currently provided by the
HSE.
HIQA has indicated that they will not have a role in the investigation of complaints. The
National Principal Medical Officer Group has written to senior management in the HSE
setting out their concerns in this regard.
With regard to the IMO’s special skills, what direction will effective child screening take in
the future given that our population is increasing and there is only a small number of
community medicine doctors, as I understand it? How do the witnesses see this panning out
if we introduce an age-appropriate annual check-up for all citizens. ….. Would like to hear
how the IMO would co-ordinate this and whether the witnesses would see the system coordinated through general practice or in some other way. (Deputy James Reilly)
Community Health doctors recognise that a different approach is needed in relation to
children. They are not mini adults; neither are they a homogenous group. The needs of
an adolescent are very different from a toddler, for example. They are dependent on
others - parents, carers, and communities. They may be unable or not allowed to speak
for themselves, have a different legal status and are vulnerable to abuse and exploitation.
Their health and well-being is more affected by social and environmental contexts. There
is compelling evidence that investing in children yields high returns. Early years’ services
including child health services have been shown to have a benefit relative to cost of seven
to one. Immunisation for children has a benefit relative to cost of fourteen to one. The
benefits are evident in all sectors from crime reduction to improved educational
performance. Community Health doctors are the medical professionals in the community
with the expertise in child developmental screening on a population basis. Critical to the
success and quality assurance of a screening programme is the requirement for a critical
mass. By this we mean a sufficient through-put of children by a medical practitioner to
develop and maintain competency in the early identification of developmental problems,
similar to the concept of centres of excellence in terms of hospital services. Their expertise
lies in their medical training and further postgraduate education, their clinical knowledge
and diagnostic skills supported by experience of working with children.
As the primary screening and surveillance programme expands in the future, both in
terms of numbers screened and the number of conditions screened for, community health
doctors are best placed at ‘first’ and ‘second tier’ levels to offer specialist assessment of
children. In our opinion general practitioners would not have the capacity to deliver this
screening programme. A further barrier to accessing such a programme via the GP is the
public/private mix – 2/3 of the population including children do not have a medical card.
The fact that access to community medical services is free to children at the point of
delivery, regardless of GMS eligibility, makes it more likely that the programme will be
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effective. Community Health doctors are currently exploring ways of integrating this
service into the overall programme for children.
Where would community medical doctors see themselves in regard to the primary care
teams? What sort of population do they feel is appropriate for each community medicine
doctor to be responsible for to provide maximum effectiveness, given that GPs and dentists
are generally responsible for 2000 people? (Deputy James Reilly)
Do the delegates see themselves mainly as linking with a network rather than a team at the
lower level? (Deputy Jan O’Sullivan)
Where do the delegates see their role as an integrated part of a primary care team? (Deputy
Rory O’Hanlon)
Community Health Doctors would see themselves working at network level providing a
range of specialised, preventative medical services (e.g. child health surveillance) to a
number of primary care teams, or across a number of networks (e.g. neonatal BCG &
school immunisation programmes). They will be available to contribute to clinical team
meetings as required for specific patients or issues. Reconfiguration of existing
community health doctors has commenced and is being further developed.
At network level they can provide input to the clinical governance agenda e.g. quality
assurance and audit of screening and vaccination programmes. They can contribute to
needs assessments at team and network level, and should be involved in interagency
community health fora to highlight and tackle the social inclusion agenda.
The population of the networks will take into account urban/rural demographics but
generally it is envisaged that the primary care teams will have a population of 7,0008,000, while the networks will have 25,000-30,000 (that is providing service for 3 to 4
teams).
Is a shortage of personnel an issue for the delegates from the community medical
committee? (Deputy Jan O’Sullivan)
What impact is the pressure on local health centres having on their work? The shortage of
staff, particularly the failure to replace key staff and those on maternity leave, makes it
difficult for remaining staff to do their job……….How much is the pressure from the
centres affecting the delegates’ work? (Senator Frances Fitzgerald)
There is a serious shortage of Community Health Doctors (otherwise known as Senior
Medical Officers & Area Medical Officers). A complement of 150WTE doctors was agreed
at national level in 2003 for the population at that time. Currently there are only
130WTE doctors in employment.
Historically, there has been underinvestment in Community Health Medicine, with a
reluctance to sanction permanent posts. In fact, many posts were actively suppressed by
HSE management in spite of significant increases in population. There has also been a
reluctance to approve the filling of posts on even a temporary basis at Senior Medical
Officer level, which is the entry grade. In addition, the substantial pay differential
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between community health doctors and other doctors such as GPs or consultants (which is
2-3 times that of a community health doctor) has compounded recruitment difficulties.
This seriously hampers the development of services delivered by community health
doctors. Examples include:
 the inability to standardise the delivery of Neonatal BCG programmes around the
country,
 the lack of standardisation in the delivery of child health services,
 the absence of an adolescent health service,
 the inability to proceed with the WHO recommended Measles Elimination
Campaign for 4-18 year olds. Furthermore, the planning and implementation of a
HPV vaccination programme for 12 year old girls was hindered by the lack of
capacity within the system.
There is no community medical child developmental screening service in Co. Laois due to
the non-filling of medical posts. Similarly, in the Dublin North-East area, there is only
limited medical involvement in child health screening.
Child health screening is provided to fulfil the HSE’s obligations under section 66,
Subsection 1, of the Health Act 1970 which states that: ‘A health board shall make available
without charge at clinics, health centres or other prescribed places a health examination and
treatment service for children under the age of six years’. Under the Act, any referral or
treatment needed as a result of these services is to be free regardless of medical card status.
In areas with no community medical involvement, parents are obliged to attend their
general practitioner for onward referral to specialist services. For 2/3 of the population
this involves a cost which is not always readily affordable and so an opportunity for early
intervention may be lost or delayed. Furthermore, additional hospital costs may be
incurred which would otherwise have been avoided. This is of particular significance,
especially for those on the margin, in these recessionary times.
Substantial evidence exists that investing in children yields high returns. Early years’
services including child health services have been shown to have a benefit relative to cost
of seven to one. Immunisation for children has a benefit relative to cost of fourteen to
one. The benefits are evident in all sectors from crime reduction to improved educational
performance.
There is no medical involvement in the statutory inspection of private nursing homes in
Dublin North-East due to the discontinuation of the doctors’ contracts, without
consultation, by HSE management. This occurred in spite of the fact that the Leas Cross
Nursing Home was located in this area.
Community doctors are also part of the HSE ‘surge’ capacity and are integral to the flu
pandemic plans. However at current levels they will be hard pressed to deliver what is
expected of them in an emergency.
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In terms of the role of community doctors specifically, will the delegates say whether the
HSE consulted them in regard to the setting up of what seems to be their primary focus,
namely teams rather than networks? (Deputy Jan O’Sullivan)
Other delegates have referred to the need for a teamwork approach. We get the impression
listening to some of the delegations that management in the HSE never take the opportunity
to talk to people. I do not understand this. Why, if it seeks to deliver a first class service in
any community……does it not get people around the table who can deliver the services
required by communities? (Deputy Charlie O’Connor)
In general, community health doctors were not consulted at the formative stages of the
process. In some areas community health doctors have been invited to participate in the
local implementation groups. This is a positive development. However, as a group, we
would welcome further meaningful engagement in this process.
The delegates have suggested that it (HPV) could be delivered as part of the school-based
immunisation programmes. Is any other vaccination programme delivered to the same age
cohort and, if so, is there room for savings in terms of the cost of delivering the HPV
vaccination programme? (Deputy Jan O’Sullivan)
In some parts of the country the dT vaccine is administered to the same age cohort
through the school immunisation programmes. The merits and logistics of administering
two vaccines alongside each other would have to be explored fully, given that HPV
requires three separate vaccine doses, given at specific intervals. However, community
health doctors are very experienced and are well placed to deliver a school-based
programme and achieve the high uptake rates required to maximise cost-effectiveness. Of
note, an additional immunisation programme would require additional resources.
The delegates refer to a role in maintaining standards of home care……..Will the delegates
respond as to how community doctors might ensure more people will be able to access
whatever supports they require in order to stay in their own homes? (Deputy Jan
O’Sullivan)
At issue is the role public health doctors fill in the community…..It works well in respect of
many of the issues mentioned by the witnesses, such as vaccinations and overall population
health. However I wish to discuss areas in which it does not work or in which potential
problems may crop up in the future. Public health doctors always have inspected nursing
homes……Obviously, inspection reports exist which would have been signed off by HSE
staff, including public health doctors. There is concern that public health doctors missed
what was going on or perhaps came under pressure from officials higher up the line to
ignore matters or to not raise issues. A change in society is under way at present, in which
more older people are being left at home. Although concerns have been raised in respect of
institutionalised care in recent years the potential for such events to happen and not to be
picked up on within the community is even greater. Have such concerns been raised within
the medical profession outside of the witnesses’ job as employees of the State? Have the
witnesses put in place systems to act as doctors, as opposed to employees of the State?
(Senator Liam Twomey)
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Community health doctors would welcome a role in the assessment of need of older people
and the promotion of their health and well-being. We have experience in identifying
unmet needs of older people in terms of housing, mobility, transport, aids & appliances as
well as involvement in medical assessment for subvention and appropriate long-term
placement as required.
The continuation of medical involvement and further
development of this role is critical given the recognised shortage of general practitioners
and geriatricians and their increasing work loads. Given that the HSE’s stated objective
is to maintain people in their own homes for as long as possible and in accordance with the
stated preference of older people, community health doctors are well placed in the
networks to ensure that the various services required are fully integrated.
Community health doctors value their professional independence and impartiality in
terms of risk assessments and recommendations they make in the course of all their duties.
The current reconfiguration of HSE structures will enable community health doctors to
bring their concerns regarding quality and safety to a higher level than is currently the
case.
It seems that in some parts of the State their discipline works in parallel with the GP service
and that there is not the degree of integration we would like to see……….It is important
that GPs should be well briefed in terms of everything happening with their patients in their
practice. (Deputy Rory O’Hanlon)
Historically it would be true to say that the systems have not facilitated ease of
communication between community health doctors and GP colleagues. This was, in part,
due to the organisational structure and the lack of resources to facilitate effective
communication. However, the new integrated structures with defined information
pathways will facilitate effective two-way sharing of relevant information. Our services
will continue to be complementary to the services provided by GPs.
Community Health doctors have always played their part as members of the multidisciplinary team in community care providing services to the population. The focus of
the team has now moved from community care to primary care and has brought the GPs
and their practice teams into the multi-disciplinary team. This obviously presents some
challenges in terms of practicalities and management, but fundamentally it is in keeping
with community health doctors’ traditional philosophy of working with colleagues for the
benefit of individuals in order to achieve the best of health for the whole population.
On prevention the delegates have listed several skills they possess…….However
responsibility for prevention is spread among many agencies, some of which are outside the
health service…………What role do the delegates play in this regard and do they have an
integrated approach with other agencies? (Deputy Rory O’Hanlon)
The view also appears to be emerging that a primary health care team to a great extent will
be a local health promotion team. Do the witnesses subscribe to that view? For example, in
the realm of immunisation programmes, how do they see the primary care team maximising
participation in such programmes? (Deputy Charlie O’Connor)
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Community health doctors through their work actively engage with other statutory and
non-statutory agencies e.g. primary & post-primary schools, local authorities, voluntary
services for persons with disability, County Child Care Committees, local partnership
groups, interagency emergency planning fora, the Gardaí, etc.
As previously stated, community health doctors are well placed to continue to provide a
link between these agencies and the primary care teams and networks, focused primarily
on the wider determinants of health and an outcomes model.
Primarily primary care teams will be service delivery teams, providing diagnostic and
therapeutic medical, nursing and therapy services. However, they will also be responsible
for promoting health. At network level community health doctors will be key to
maximising uptake of surveillance and immunisation programmes and ensuring the
quality of such programmes through being involved in monitoring and audit. They
deliver evidence-based primary prevention programmes (e.g. immunisations) and directly
inform and support healthy choices during clinical contact with clients. They are
involved in secondary & tertiary prevention (i.e. limiting the effects of
impairment/disability) through their work with specific client groups. They take the
population health and social inclusion approach and ensure that all sectors of society
benefit from the evidence-based programmes that are available.
What is current capacity in terms of the assessments the delegates undertake, whether for
the Domiciliary Care Allowance or other services, and to what extent are there waiting lists?
(Deputy Jan O’Sullivan)
There are waiting lists for assessments and services provided by community health
doctors. The waiting times vary around the country and are dependent on the medical
manpower resources available to service this need. Pressure on all services provided has
been exacerbated by demographic changes which have increased demand for services,
especially in the high dependency groups (i.e. children and the elderly), without a
commensurate increase in the staff complement, as outlined in the response to an earlier
question.
Another factor contributing to delays in the processing of applications is the lack of
capacity in other services to provide relevant timely assessments and reports. A big issue
for the future will be the capacity for community health doctors and other professionals to
assess children and plan and deliver recommended interventions within the time frames of
the Disability Act. This threatens to overwhelm the system.
Can the witnesses give the Joint Committee the benefit of their experience on the issue of colocation? (Senator Sean O Fearghail)
Co-location is the preferred option, as it has advantages for both service users and
professionals working within teams and networks.
For the service user the advantages include a high visibility facility which provides an
easily accessible one-stop-shop service. A multiplicity of services provided in one location
also facilitates a degree of anonymity for the users of some specialised services. In
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addition, well-designed and adequately resourced premises will facilitate outreach hospital
and specialist services in the client’s own community.
For the professionals co-location facilitates inter- and intra- disciplinary communication,
team-building and the development of mutual support networks resulting in better
outcomes for service users and better quality services.
Continuing professional
development and clinical governance will be facilitated in this model. In the interim, in
the absence of co-location, it is essential that every effort is made to facilitate effective
communication within teams, and between teams and networks. The development of
integrated IT systems is of paramount importance in achieving this objective.
Looking towards the future of primary care what single most important change would the
delegates recommend, given current economic limitations? (Deputy James O’Reilly)
Community health doctors would wish to be adequately resourced to provide the
evidence-based and cost-effective services they already provide, equitably throughout the
country. They would wish to develop and take on roles appropriate to their skills and
qualifications that are in keeping with their unique population health approach. In
addition, they wish to continue to advise the management of the HSE on clinical and
wider community and public health issues in the new structures and to reinforce their
legitimate role in strategic and operational developments, both locally and nationally
We thank the Joint Committee for this opportunity to answer more fully the questions posed on
the day of the oral submission and for your recognition of the importance of our service in
primary care. We request that you include this written submission in your final report to the
government. We remain available for further engagement should you request this.
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