DRAFT
General Practice Development
A Time to Reflect & Debate
We are experiencing now a period of fundamental change in our health services which
pose both threats and opportunities for us all in General Practice and as such we
should reflect and debate the issues which could shape the future of our work in the
coming decade.
In that context the ICGP welcomes the various encouraging statements on the role of
Primary Care by Professor Brendan Drumm, CEO, HSE and by Dr. Sean McGuire on
behalf of the HSE outlining the key issues which the HSE wishes to address in the
context of the negotiations between the HSE and the IMO. Whether the coming round
of negotiations will constitute ‘the greatest opportunity in generations’ remains to be
seen.
Their statements set out, in broad terms, the aspirations of the HSE for the
development of General Practice. It is useful to have this analysis of the current state
of General Practice and the HSE vision of how it might contribute to a better health
service set out publicly for all to consider.
These negotiations will not be a single once off exercise culminating in the next few
months. Clearly there will be issues prioritised which may be signed off in this current
round. However, under discussion will be the future delivery of General Practice and
Primary Care services and the future development of general practice in the context of
the wider development of the health services. This must be an ongoing process over
the next number of years as it embraces enormous change. It must be implemented on
the basis of open debate and sound decision making.
The broad strategy of HSE to re-orientate the health services towards primary and
community services is very welcome.
D:\116097947.doc
-1-
Preserve the Strengths of General Practice
In any debate on the future of Irish General Practice we should start by reminding
ourselves of its key strengths.





Irish Patients have real choice of practice including doctor, nurse, and other staff.
Practices compete for the privilege of serving patients and their families.
Patients can establish substantial personal continuity with their doctor or nurse
who can use that knowledge to provide individualised solutions and care.
Practices aim to solve patient problems by providing the best services there and
then or by proposing solutions through referral.
Ownership and control is vested in the practice partners, who have a real interest
in providing quality and have the power to make practice decisions quickly
including the commitment of resources if necessary.
Going back to the Primary Care Strategy
It has been suggested that the concept of primary care teams be resurrected under an
ambitious plan to roll out up to 100 new teams this year. Currently there are
approximately 2400 full time equivalent GPs working in 1600 practices.
The Primary Care Strategy, while containing much that was valuable, had a number of
serious flaws and was regarded as unacceptable by a majority of General
Practitioners.
For Example






It was unclear how many GPs on average would be included in a ‘team’
Many of the projects required new premises and much of the new funding was to
go into buildings.
Team size as proposed was impractical for daily communication because it was
unclear how many health professionals would be involved.
Much time was to be spent on activities other than ‘hands on’ patient care.
Roll out of the initiative was to be incremental. This would give an advantage to
some practices and not to others. This seriously threatened the basic concepts of
equity for all patients and fair competition between practices.
Added to that
o It was too slow. It was to take years to reach all practices.
o It was inherently unfair in any system based on choice.
o The unit size of a ‘practice’ was too large making real patient choice and
competition unlikely outside larger cities.
The new plan to roll out 100 new teams this year whilst very welcome as a statement
of commitment, ignores the substantial difficulties encountered by those who
attempted to implement the Strategy at the 10 pilot sites over the last three years.
D:\116097947.doc
-2-
Even if successful and followed by 100 teams /year for the next five years, will all
practices be included? ICGP estimates that the total no. of practices is 1600.
Therefore resurrecting the concept of the enlarged primary care team, and announcing
plans to roll out up to 100 new teams, may not be any more acceptable to GPs now
than it was the first time.
Rather than reverting back to the selective approach of the Primary Care Strategy
should we not make a similar sum available to any practice submitting plans for
service development. Practices could be assisted to prepare worthwhile business
plans. Selection criteria for proposals reflecting the policy priorities of the HSE and
acceptable to GP representatives should be agreed. The agreed criteria might also
reflect the aspirations of the Primary Care Strategy.
Community Intervention Teams
It is proposed to establish new ‘community intervention teams’ (a rapid reaction
group of health professionals on call from 8.00am to 10pm). This would require the
availability of other health professionals outside normal working hours. This would be
welcomed by most GPs.
The Choice of Two Contracts – ‘Standard’ and ‘Enhanced’
It is proposed that there would be two contracts (or two layers within the contract).
The ‘standard’ contract will apply to most GPs and the ‘enhanced’ contract would
facilitate the delivery of chronic disease management by some fraction of the total.
This proposal appears to suggest a permanent two tier service (some practices will
offer chronic disease management, while others will not).
This is unacceptable other than in the short term. ICGP is committed through its
approved training programmes, its CME activities and its standards of practice to a
uniform comprehensive quality service. The definition of general practice includes
optimal chronic disease management for all patients.
However there may be circumstances where some new service is being developed and
is not being provided by all doctors/practices in the short term. Where that happens it
is assumed that the new service will quickly become established.
Real service innovations must attract additional remuneration to reflect the improved
level and quality of service. Additional time will be required and more staff may need
to be recruited, and extra space provided. Some retraining may also be required.
D:\116097947.doc
-3-
Using the Contract to Incentivise Group Practice and the Use of ICT
More than a third of all Irish GPs works in single-handed practice. This is not always
by choice. In the past single handed practice was mostly a feature of remote rural
areas – now it is common in centre city Dublin.
ICGP would support incentives in the short term, aimed mostly at single handed GPs
wishing to join practices of 5 partners or less. Seeking to reconfigure General Practice
by restricting access to some contracts is unacceptable. In rural areas ‘virtual teams’
(including other health professionals) and ‘virtual partnerships’ should also be
supported.
Use of ICT is progressing rapidly in both quantity and quality but should continue to
be encouraged by incentives that particularly reward use. Universal patient
registration should now become a priority.
Using the contract to encourage Teamwork
ICGP would support incentives for those doctors and practices who agree to work to:
 to a standard protocol;
 to share resources;
 to work like a team in terms of staffing;
 to have clinical meetings to discuss the management of patients.
 To provide continuing professional development for all the team members.
These activities, however desirable, reduce the ‘face to face’ clinical time available
for patients. This in turn requires additional staff and resources.
Chronic Disease Management – ‘Heartwatch’
ICGP agrees ‘that chronic disease management is ideally done in the community.’
We welcome the support of the CEO in promoting this message. While we reject the
suggestion that GPs don’t have ‘all the expertise to manage diabetes, asthma, heart
disease, etc.’ we welcome the added expertise of practice nurses and other health
professionals in providing these patients with optimal care as part of a team.
ICGP agrees that priority be given to ischaemic heart disease and diabetes, based on
lessons learned from ‘Heartwatch’ and the Diabetes Scheme in the Midlands.
‘Heartwatch’, which is continuing in its existing format for another year, is the model
for chronic illness care in Ireland. As originally proposed by the ICGP ‘Heartwarch’
was to have been rolled out to all practices within 5 years. If all GP Practices were
given the opportunity to be involved it would greatly simplify the payment system.
‘Heartwatch’ represents a serious commitment to better care for the participating
patients – it must not be used as some sort of bargaining counter in the resolution of
arguments about contracts and money.
D:\116097947.doc
-4-
Primary Care and the Community Sector
It has been suggested that any supposed division between primary care and the
community sector is an artificial one, and that they can be viewed as a single entity.
This is unrealistic - the division between the two sectors exists.
Those working in Primary Care are ‘generalists’ who are committed to the ongoing
comprehensive care of a list of named individuals. These patients and their families
have chosen this particular practice and its staff. The staff expertise is based on their
knowledge of each individual shared between members of the practice team.
In contrast those working in the Community Sector are ‘specialists’ providing
specific care to patients who need their particular expertise usually only for a limited
time. There are more than 30 different types of professional included. Their expertise
is best employed by formal referral which provides only relevant patient information
and requests further investigation, and/or treatment. They are not part of the primary
care team but are equally essential, community based, specialists.
Attempting to ‘lump’ all these professionals together in some notional ‘super team’ is
not only unnecessary and unwieldy, but wastes much valuable clinical time satisfying
the needs, not of the patients, but of bureaucracy
Funding, Accountability & Transparency
ICGP accepts that accountability is a key factor. We agree that what primary care can
deliver is transparency and are encouraged by HSE confidence that funding can be
found.
We agree that infrastructure will be a significant issue in developing a more elaborate
service. Imaginative flexible solutions are required for investment in better facilities.
Public/private partnerships should be devised. Various forms of ownership should be
considered. In deprived areas special arrangements may be needed.
ICGP welcomes the recognition of the need for funding. However it urges the parties
to simplify the bureaucracy and widen the definition of investment to enable practices
to address their priority needs.
The Development of 75 – 100 Primary Care Teams
ICGP understands that funds have been allocated for a new plan to build up to 600
teams over a number of years, as provided for in the Primary Care Strategy. It seems
to be accepted that there are already inequities in general practice and that moving to
team-based service delivery will inevitably add to these, at least temporarily.
It is proposed that each of the 32 Local Health Offices will have access to €500,000 in
revenue to fund three new teams in their area on a permanent basis. These are not
‘pilots’.
D:\116097947.doc
-5-
The fact that this is revenue funding is reassuring. However balance must be
maintained between buildings and equipment on the one hand, and additional
personnel, services, training, IT support, and review on the other. More fundamentally
these initiatives in selected practices create unfair advantage in a system of competing
services based on choice.
Direct Access to Diagnostics for GPs.
In Cork City a procurement process is ongoing for €300,000 worth of diagnostics for
GPs. HSE hopes GPs can organise an increase in the capacity, using existing facilities
within the community, and improving how hospital-based capacity is used perhaps by
extending times for operating. Consultant radiology appointments could also include
dedicated sessions for the community.
GPs as independent, private sector, contractors should be capable of organising these
services for their patients or of doing so as members of their co-ops or similar such
groupings. These improved services then become available to all patients.
These and the other developments listed here are key factors in achieving transfer of
care from secondary to primary care settings. GPs must be involved in these
developments and ways found for them to do so without loss of income.
Direct Access to Hospital Treatment /Surgery for GPs
The next logical step would be direct patient access to surgery, based on appropriate
scans done in General Practice. The ultimate aim is patients perceiving the advantage
of having tests in the primary care setting, rather than in hospitals.
Direct Access to Hospital Admission for GPs
Patients who have been assessed by a GP should be fast-tracked through the hospital
system. They learn to avoid a six-hour wait in A&E by visiting their GP.
GP involvement in the ‘change’ process
ICGP supports these developments in principle. ICGP welcomes them particularly if
they are accompanied by the recognition that much ‘new work’ will be involved in
planning and implementing new systems. Funding and locum cover must be available
for the GPs who take time out to consult, plan and execute the new systems.
Long Stay Hospitals and Community Intervention Teams
ICGP supports the proposal for substantial funding to be provided for long-stay
elderly hospital patients as well as improving generally the care for older people.
We welcome proposals for the ‘Community Intervention Teams’ to be introduced in a
number of cities. When called in by the GP they will assess and provide necessary
social support and all services needed by patients to overcome acute illness or arrange
fast-track admission, thus reducing the number admitted for social reasons. The teams
will be available from 8 am to 10 pm. Once contacted services should be follow
within 24 hours. ????
D:\116097947.doc
-6-
This is the start of having primary care services available out of hours - not just GP
services. ICGP supports these measures particularly if they can prevent unnecessary
admissions through A&E Departments.
Review of the GP Contracts
ICGP welcomes the commitment to use the contract talks to improve the lot of
younger GPs. One third of GPs will retire in the next 10 to 15 years. There has to be
greater access to GP contracts which must be more flexible. Job sharing can allow
GPs working together to contract for 24/7 responsibility.
The current 1970 contract needs complete review. Any new contract must include
both the practitioner and the practice; it should define a common age of retirement; it
should include all areas of clinical activity including preventive services, mother &
child care, etc; it should promote long term stability and commitment; etc.
Flexible working hours must also be accommodated but not prescribed;
However, younger GPs must realise that not all GP vacancies will occur in the
location of first choice.
It has been suggested that a GP would, in their contract, agree to have at least one
surgery in the week that starts at eight in the morning and at least one that would
finish at eight in the evening. Single-handed GPs working in virtual teams could come
to some arrangement as to how this might be met in a way that served patients in their
area.
Provided the need is established and the compensation for working unsocial hours is
attractive, many GPs might be prepared to offer to provide services in the early
morning or late evening. But any such proposals should be voluntary. Such proposals
must also take account of existing out-of-hours arrangements in the area including GP
Co-op arrangements.
Equally ICGP supports more flexible contracts for younger GPs and part time
working, provided that it is realistically remunerated and negotiable.
Out-of-HoursServices
ICGP is committed to a GP service available 24/7. We have set out standards in
relation to ‘Out-of-hours’ services.
Out of Hours services should be provided by GPs themselves or by suitably qualified
locums. The qualification standard that has been applied within Co-Ops (on the advice
of the ICGP) has been MICGP or equivalent or three years full-time experience in
general practice.
D:\116097947.doc
-7-
Models now exist throughout the country, which combine reasonable working hours
for doctors (and their families) with quality services for patients ‘around the clock’.
These should be implemented everywhere.
In conclusion
In addition to the specific items addressed in this document and the Joint IMO/ICGP
Vision document, published 2001, there are some issues of process which should be
included in any final agreement at this stage.
The contractual agreement between the GPs and the HSE should be a dynamic
evolving process rather than a ‘final solution’ reached once every 15 years. More
flexibility is required particularly now when substantial change is expected in the
short to medium term.
KEY POINTS OF HSE PLAN FOR PRIMARY CARE








75 – 100 primary care teams located across the country this year;
More community based diagnostic services;
Two types of GP Contract: a standard contract for most doctors and an
“enhanced contract” for those managing chronic illnesses;
Flexible contracts to encourage younger GPs;
GPs to operate at least one surgery starting at 8.00am once a week and at least
one surgery opening until 8.00pm once a week;
Incentives for group practices and effective use of ICT;
Financial support for primary care team building;
Community intervention teams to provide a “rapid response” primary care
service.
D:\116097947.doc
-8-