Dr Tom O’Connor
College Lecturer Economics, Public Policy &
Healthcare
Cork Institute of Technology
Speaker Profile
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GPs have to be ‘renaissance’ people!
GPs have a wide area of coverage
I am the same!
I teach economics, public health, social policy
I research and write on: public finances, taxation, industrial policy;
public health, social care, health policy/economics
I am passionate about fairness: have done quite a bit of media work in
this regard.
GPs have large contact hours
I work in an IOT and teach 18 hrs per week (upt two since Haddington
Road)
Like GPs, I teach practitioners in the area of social care.
Member of Economists’ Network at TASC; Chair of SWAN Cork
Book plug! O’Connor, T ed (2013) Integrated Care for Ireland: articles
by: Cork GPs, Diarmuid Quinlan, Joe Moran; ICGP; IMO; Prof Des
O’Neill; Ivan Perry; Steve Thomas; Eithne Fitzgerald: John Saunders
and more.
Outline
 The Macroeconomic context of Public Health in Ireland
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under Austerity- Govt going in the Wrong Direction
Centrality of the Primary Care and the GP, referencing the
Secondary Health Care System- yet continuing neglect
DOH/HSE ‘new’ Policy on Health & Social CareIntegrated Care.
Government Policy at Odds with HSE Integrated Care
Policy
Reality in the Real Health ‘Angola’
Conclusions
Austerity
 From 2008-2014 inclusive: 31.5 billion in public
spending cutbacks and tax increases.
 In 2011, the most recent year for which full figures are
available, total health spending in Ireland (OECD),
was 8.5% of GDP. Of the 29 countries surveyed,
Ireland had the 21st highest level of health spending. In
other words, we were eight from the bottom of the 29.
Budget 2014
 Budget 2014: 113 million ‘savings’/cutbacks in medical
cards. At least 150,000 cards. Runs contrary to the
Population Health of DOH & HSE.
 Cut in 25 million to over 70s medical cards, at least
20,000 medical cards
 Minister has stated he doesn’t know how many
medical cards will be lost!
 Complete lack of evidence base regarding public
health.
 35,000 over 70s to go from full to doctor-only medical
cards
Free GP Care Under 5s
 If we combine the cuts of 117 million on medical cards with
the introduction of free GP services for under-fives, it is
clear that the services for relatively poorer and sicker
people is being used to fund a universal service that has no
new fresh income stream of dedicated funding.
 While, the roll out of free GP care for children under five
years is to be welcomed, it is of little comfort in the context
of the savage attack on poorer people’s medical cards.
Further, the figure of 37 million is substantially inadequate;
Census 2011 shows that there were 421,000 children in
Ireland under the age of five. This means that GPs will
receive a gross amount of 95 per child per annum
Getting it Wrong: Troika
 The EU Commission, as part of the Troika is
demanding savage health and social care cuts going
forward. In the last fortnight, despite the draconian
budget 2014 cuts announced, the EU Commission has
called for a further ratchetting up of cuts in the
health/social care budget. This is based on their
perception that cutbacks can be made, given that
Budget 2014 estimates health spending at 13.3 billion.
Stuckler & Basu
 Stuckler, D & Basu, S (2013)- The Body Economic: Why
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Austerity Kills
Verifiable evidence of increase in mortality and morbidity
directly attributable to austerity.
Greece, 2011-13 – increase of 200% in HIV due to cutbacks
in HIV Prevention Budgets
Dramatic increase in suicide and depression in Europe and
North America
“Our politicians need to take into account the serious - and
in some cases profound - health consequences of economic
choices," [Dr Stuckler-RTE News April 29, 2013]
Health Spending Mythology
 “Starting from 2010, a sharp reduction in health
spending led to a decrease in the health spending
share of GDP”(OECD 2013:1).
 In 2011, the most recent year for which full figures are
available, total health spending in Ireland (OECD),
was 8.9% of GDP, below OECD average of 9.3%. Of the
29 countries surveyed, Ireland had the 23rd highest
level of health spending of 35 countries. We were in
the bottom 40% of countries in health spending.
Going in the Wrong Direction
The decrease in health spending since 2010 (OECD) in
fact should be rising, from a population health
approach, which the DOH/HSE says it is strongly
committed to: The population of the Irish state
according to the most recent Census (2011), rose by
348,404 from 2006 to 2011 and by 312,000 from 2002 to
2006. In fact, Ireland still has a rapidly growing
population. It rose by 1 million from 1996 to 2011.
Breaking the Primary Care
Lynchpin
 “The cuts of 7.5% to GPs are indefensible based on the
population health evidence which now presents itself.
In the wake of a massive decline in hospital beds, an
inadequate number of hospital specialists and growing
waiting lists, and a dramatic rise in mental illness and
suicide, the GPs are holding the Irish health system
together”
(Tom O’Connor- Irish Times Sept 2, 2013)
Capitation Payments: circular HSE 009/2013
GMS PCRS 2013 Post-FEMPI
Males
Under 5 years
5-16 Years
16-45 Years
45-65 Years
65-70 Years
Over 70 in Community
Over 70 in Nursing Home
Medical Card Holders 5.3 visits
pa. Non-Medical Card Holders
2.2 visits pa (ESRI 2005)
€
74.59
43.29
55.26
110.38
116.28
271.62
434.15
Critical Importance of GP
 Ireland has 141 specialist medical practitioners per 100,000
of the population, the second lowest of 26 countries
(mainly EU) surveyed by Eurostat. Only Turkey is lower
with 121 per 100,000. Germany has 216; Spain 240 and the
UK 192.
 The role of the GP is critical in all HSE plans prevent
hospital admissions and move more to community care.
 This is further evidenced by the fact that the GP is to keep
people out of hospital in an a country characterised by a
critical shortage in hospital beds (next slide)
Incentivised Payments: Asthma
 “These quality markers are derived from both the British
Thoracic society and the Scottish Inter-Collegiate Guidelines
Network (SIGN) guidelines. The guidance explicitly states:
 “It is important that resources in primary care are targeted to
patients with greatest need - in this instance, patients who will
benefit from asthma review rather than insistence that all
patients with a diagnostic label of asthma are reviewed on a
regular basis”.(6)
 The success in the UK lies in sharp contrast to the documented
outcomes in Ireland, as outlined above: almost 20,000 A&E
attendances and nearly 5,000 hospital admissions, and 62
asthma deaths in 2011(4). The UK system rewards clinical
excellence. The Irish system does not. The sole payment for
asthma management under the GMS is a fee for nebulisation of a
patient with asthma. This is a perverse disincentive to high
quality structured care” (Quinlan & Moran 2013:154)
Hospital Beds
per 100,000
1999
EU (27
countries)
2003
2007
2009
2010
649.2
603.4
564.6
550.8
538.2
Belgium
Czech
Republic
781.4
750.8
663.1
650.8
644
773.6
772.2
730.6
711.4
701
Denmark
Germany
Ireland
Spain
438.8
919.4
624.5
374.8
413.3
874.4
567.2
345
369.1
823.9
514.6
327.2
349.4
823.9
327.4
318.7
349.8
824.8
313.9
315.7
France
820.1
754.6
706
665.9
642.4
Italy
492.7
415.9
384.5
362.6
352.5
Hungary
824.9
783.5
718.6
714.4
718.2
504
450
474.2
465.7
:
Austria
808.2
773.3
774.7
765.9
762.9
Portugal
376.2
358.8
341.4
335.2
334.7
Slovakia
795.3
723.8
675.3
650.5
641.8
Finland
760.5
724.3
673
624.5
584.7
Sweden
United
Kingdom
369.8
305.1
286.4
275.9
272.6
:
395.4
340.7
329.1
295.5
Netherlands
Hospital Beds: International
Comparison
 “Ireland also has the 4th lowest number of hospital
beds per 100,000 of 28 Eurostat surveyed countries at
313.9, with an average of 538 beds across the 28.
Germany has 825; France 642 and Portugal 347 (all
figures for 2010 the most recent). As recently as 2004,
Ireland had 564 hospital beds per 100,000”(O’Connor
Irish Times 2-9-13)
Centrality of GPs in Primary Care
 Strong evidence in HSE policy that GPs are pivotal in delivering
integrated health and social care in the community.
 This goes back to the Quality and Fairness Health
Strategy/Primary Care (2001)
 Centrality of GPs underlined in all DOH/HSE reports,
particularly since the 2001 strategy.
 Primary Care teams, GP at centre and Primary Care Teams (DOH
2001)
&
 HSE Integrated Services Model (HSE NSP 2011)
 Many others also
 DoH Health Strategy (2001) next slide
Primary Care Team
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
Source: Dept of Health (2001:24) Primary Care a New
Direction: Quality and Fairness - A Health System for You
Health Strategy
Note: new choice of professionals:
podiatrists; OTs; SLTs etc
HSE (2006) Health Transformation
Priorities
 Priority one: 'Develop integrated services across all stages
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of the health journey'.
Priority two: 'Configure primary, community and
continuing care services so that optimal and cost effective
results'.
Priority four: 'Implement a model for the prevention and
management of chronic illness'
Priority six: 'Ensure all staff engage in transforming health
and social care in Ireland‘
This integration/transformation in HSE Integrated
Services Model and National Programmes of Care (Mc
Callion 2010; HSE NSP 2011, next 2 slides)
Level IV
Tertiary Acute Services
Level III
Integrated Service Areas
(Including Secondary Care Hospitals)
Level II
Community Health &
Social Care Networks
Level I
Primary Care Teams
Home
Home
100,000-350,000
30,000-50,000
7,000-10,000
Patient
Primary Care
Care of the elderly
Palliative Care
Radiology
Obstetrics and
Gynaecology
Obstetrics and
Gynaecology
(Deputy)
Joint Stroke
(Geriatrician)
Joint Stroke
(Neurology)
Acute Coronary
Heart Failure
Diabetes
COPD
Asthma
Mental Health
Epilepsy
Dermatology
Neurology out
patients
Rheumatology
Joint Acute
Medicine
Joint Acute
Medicine
Emergency
Medicine
Critical Care
Surgery
Syndrome
Unrealised Optimism
“Mc Callion (HSE) pointed out in 2010 that 531 Primary Care Health
Teams (now abbreviated to just PCTs) had been mapped out for the
whole country to cater for these and other health care needs (level 1).
Indeed, the following year, the HSE National Service Plan (2011c)
confirmed that these had been formed and were in place. However, the
Health and Social Care Networks (level 2) were still work in progress in
2010. Given that patients require a discharge plan before they can be
safely left return home, as part of the new hospital configuration
programme, hospital populations were to be synchronised to where
integrated services were being rolled out. Integration was to happen by
transferring ‘non complex acute services to local hospitals and/or
PCTs'(Mc Callion 2010:11). These smaller local hospitals would work in
close co-operation with PCTs and would have 'co terminous
populations'. These non-complex hospitals are situated at level 3 of the
integrated services model. The Primary Care Health Teams would be
designated in to eight Integrated Service Areas (ISAs) nationwide but
the PCTs (previously named PCHTs) would represent 'the building
blocks for an integrated service area'(Mc Callion 2010: 12)
(O’Connor 2013: 20/21)
HSE Model at Odds with Govt
Funding
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Teams have common goals based on healthcare outcomes and
shared values. They also have shared standards and operating
processes;
• An average of five PCTs will make up a Health and Social Care
Network (HSCN) serving a wider, but related, population of 30,000
to 50,000 people;
• HSCNs will include a pool of specialised resources that serve PCT
communities;
• PCTs and HSCNs will be integrated with hospitals, multi-agencies,
private providers, voluntary agencies, and with support groups
(HSE, 2010a: 9).
Primary Care Centres
‘An investigation by The Irish Times journalist, Paul Cullen, based on
statements from the HSE and reports of meetings that took place in
2011
and 2012, reveals that, as of 2011, 297 PCCs needed to be sited and
provided to house 415 PCTs (Cullen, 2012). A smaller priority list of 200
was put forward by Róisín Shortall in April 2012, based on extra
weighting being given to areas of social deprivation. A final priority list of
30 was finalised later in 2012. The controversy between Ms. Shortall and
Minister Reilly arose when she perceived that five extra centres were
added by him in July of that year, of which she was unaware and where
the correct criteria to justify their addition to the list was absent. This list
of 35 was released to the press. It included Balbriggan and Swords. The
public controversy that erupted resulted in the resignation of Ms. Shortall
mid allegations that Minister O’Reilly had pulled a ‘stroke’
(O’Connor 2013: 33 )
Sample of PCC Progress Cork
Location
No PCTs HSE RSP (2011)
Update HSE RSP (2012)
Update HSE RSP (2013)
2
Status HSE South RSP
(2011)
Plans being prepared
Kinsale
No update
Work in progress
Ballineen
1
Negotiations underway
Cobh
1
New draft plan awaited
Up and Running (not
noted in HSE)
Work in progress
Newmarket
1
Clonakillty
1
Site location agreed-plans
to be developed
Potential site identified
Proposal subject to HSE
Approval
Agreement for Lease
signed Completion Q1
2014
Agreement for Lease
Signed Q1 2014
No update
Fermoy
2
Negotiations ongoing
Negotiations ongoing
Mayfield
1
Discussions ongoing
Discussions ongoing
Bishopstown
3
Location to be determined No update
No update
Glanmire
2
Progressing
No update
No update
Castlestownbere
1
No update
No update
Carrigaline
2-3
Proposal subject to HSE
Approval
No update
Mahon
2
Up and running
Up and Running
Carrigtwohill
1
Letter of Intent Issued:
Negotiations ongiong
Going to HSE Board
February 2011 for
approval on rental details.
Lease agreement close to
completion
Layout plans finalising
No update
Operational 2013 (e)
Ballincollig
3
Layouts agreed: two sites
No update
No update
Work in progress
Work in progress
Work in progress
Unrealised HSCNs & Torturous PCC Progress
 “The reconfiguration objectives are
those related to deinstitutionalisation, as confirmed by the subsequent report on
Congregated Settings as discussed below. At the moment, there are
supposed to be 134 Health and Social Care Networks (Irish Medical
Times 2011) established to integrate with the primary care teams
and further on to levels 3 and 4. However, apart from a change in
nomenclature, there is little evidence of the actual existence of
these HSCNs, presumably because most of the Primary Care
Centres are not available to house the 531 Primary Care Teams that
would integrate with these 134 Health and Social Care Networks.
This would seem to be a significant challenge going forward.
 (O’Connor 2013: 35)
 As of 2012- still a need for 297 Primary Care Centres to house 415
Primary Care Teams (Cullen 2012)
Mental Health: Vision for Change
 Primary Care Teams and Community Mental Health Teams
(Vision for Change 2006)
 Monitoring Group for Vision for Change Report (2011) ‘Mental
health services had taken a “proportionally much greater
reduction in staff numbers” than other areas of the health
service, submissions to the body had said. The public service
recruitment embargo made it “extremely difficult” to change
mental health services as per the plan, the report said ....There
were some 1,500 vacant posts in community health teams which
were “poorly populated”, it said. There had been “very slow
progress” in fully staffing community mental health teams, it
found. (Irish Times 18-07-2012).
 Drip-feeding of amounts: 20-35 million per annum still
happening.
 Budget 2014: 20 million is very inadequate, given scale of
problem of mental health and suicide
Primary Care- Critical Importance
‘Other interventions such as
Falls Clinics in the
community for older people and enhanced geriatric
community care, all liaising between primary care teams
and health and social networks, are designed to keep
people from being fully admitted to hospital or having to
go in to nursing homes. In mental health Community
Mental Health Teams are planned to liaise with Primary
Care Teams to fulfil the gold standard of keeping mentally
ill patients at home and utilising the same objective for
the general population, the disabled and others with
chronic or acute conditions, such as Diabetes, Asthma
and other illnesses’ (O’Connor Irish Times Sept 2, 2013)
Disability & Older People-Lack of Health Promotion/Care also
Impacts on Primary Care
 Integrated Services Model applies to disabled and older people in particular, who
need more health and social care support.
 ‘‘HSE Primary Care teams should be the first point of access for all medical and
social care including public health nursing, home help services, meals on wheels,
social work, psychological interventions, with a clear pathway to secondary
specialist disability‐specific teams when required’(HSE 2011 – Time to Move on
From Congregated Settings:9).
 ‘These support services have been ravaged by public expenditure cutbacks since
2008: for example cuts of up to 1 million home help hours have been introduced by
the HSE in 2012 (Wall 2012); there has been an embargo on the public service
recruitment which includes social workers. Even social work services in child
protection have witnessed dramatic increases in caseloads to the point where they
have ‘Big caseloads being juggled with little support’ (Irish Independent 21-6-12).
These cuts are typical of those running across the infrastructure that is being
planned for the delivery of integrated care, making it difficult to see how it the
plans can be translated in to reality in the short-to medium term’
O Connor (2013: 36)
 The GP practice is the buffer when an old person falls, there is a COPD episode, or
asthma or other preventable health problems occur amongst disabled or older
people.
Commentary
 Blackrock Hall only PCC in Cork City- success property
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development
Are GPs expected to join consortia and become ‘team
players’ and ‘property developers?
In fact, anecdotal evidence that many GPs are in serious
financial difficulties
GPs have pulled out of PCTs in August 2013-based on the
impasse between reducing resources going to GPs and the
increased workloads/policy plans on PCTs.
Also, Blackrock Hall charges those with medical card as
private patients for multi-disciplinary services in
physiotherapy and other associated health/social care
interventions.
Reality Bites
 Ex-Minster for Health Brian Cowen once described the Department of
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Health as ‘Angola’
The Primary care environment is becoming the real ‘Angola’.
‘As of Jul 1 2013, on the back of a 96% rise in hospital waiting lists, the
total number reached 48,279, with 3,062 waiting between nine and 12
months and 653 more than a year’(O’Connor Irish Examiner 7-11-2013)
‘More than 90% of all health care is delivered at the primary care level
by GPs, nurses and associated health and social care practitioners. In
2011 we had 532,000 people over 65 years. In 2031, we will have more
than one million. There will also be an increase of 370,000 people aged
45-64, according to Census 2011 Population Projections’.
(ibid)
The care of older people is under enormous stress now, prior to the full
effect of population ageing!
Hospital Discharge
 Discharge Planning:
 “It is important to recognise that discharge from a hospital
is a process, not an isolated event involving the
development and implementation of a plan to facilitate the
transfer of an individual from hospital to an alternative
setting where appropriate. Components of the system
(individual, family, carers, hospitals, primary care
providers, community services and social services) must
work together to ensure an integrated person centred
approach and best outcome for the individual”
(Willie Reddy- HSE Programme Manager in Tom
O’Connor Ed (2013) Integrated Care for Ireland.
 Discharge to what?
Carers
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Carers Association consultation (2013):
Cuts of a million home help hours in two years
Home care packages are becoming almost non-existent
Rationing of incontinence pads; reduction in quality and
size
 Reduction in respite grant in last budget
 Demands on GPs dramatically increasing (IMO 2011-13):
older people with multi-system diseases; mentally ill;
disabled; decline in public health since austerity in the
economically developed world inc Ireland (Stuckler & Basu
2013)
Primary Care & GPs becoming the only
‘ports in the storm’
 Dramatic rise in suicide to 500 in 2012- an increase to
30% of those with a mental illness, up from 25% in
2006.
 ‘It is virtually impossible to get Cognitive Behavioural
Therapy on the public health system which tens of
thousands need as the most proven intervention. GPs
are again left trying to manage the situation and the
various categories of patients including those with
serious illnesses such as Bipolar and Schizophrenia,
but also those who are addicted to alcohol and
drugs’(O’Connor Irish Times Sept 2, 2013)
Conclusion
 Health and Social Care are in a worse crisis than at any time in
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the past 40 years
Can GPs get the public on their side?
GPs and the media- presenting the ‘truth’ .
Incentivised payments a ‘double-edged sword’ under current
circumstances?
The necessity for an Association such as NAGP is vital.
GPs need to engage in political economy discourse
The Irish government is ignoring clear evidence of severe
damage to GP Practices and Public Health
Multiple ‘coalitions’ between service user groups, other
professions and GPs need to progressed in the battle for public
health.