If we get the organisation on diabetes care right, better management for other diseases will follow, but if we don’t get it right our health services will rapidly become overwhelmed. This was the opinion of Dr Joe Clarke, GP lead, Primary Care Division of the HSE and a GP who was addressing the Inaugural Conference of the National Programme for Diabetes in Farmleigh, Dublin on “Chronic disease management – planning for the future’.
In order to look at forward planning, according to Dr Clarke, the first thing is to really look to see where are we now; to analyse the demographics of our population today and then to project what it will look like in five, 10, 15 and 20 years time.
Dr Clarke referred to the 2011 Programme for government which stated the intention to incentivise GPs to play a greater role in chronic disease management.
“One of its aspirations was that a new GP contract would provide incentives for GP’s to care more intensively for patients with chronic illness ”
He observed that there are several problems in this however, not least being a manpower crisis in general practice alongside a swell in the demographic segments that will most need chronic disease management.
While according to Dr Clarke, it’s “presumed that GPs are going to deliver a huge chunk” of this chronic disease care within primary care, we need to look at increasing the involvment of nursing, and develop a different care model than just relying on GPs delivering care directly.
Looking at the demographics, we are at the highest population level now in the Republic of Ireland since pre-famine times in the 1840s. The population has grown from 3.5 million to 4.6 million since 1992. This population growth has been much greater than our European counterparts, where some populations are actually falling (see Figure 1). Taking the census for 2006 and 2011, with projections from present through 2017 and you can see that the population is set to increase, with the over 85s segment doubling from 2006 to 2017.
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“This has huge implications in terms of chronic disease and management as large numbers of older people with chronic disease engulf the whole system,” said Dr Clarke.
He took the audience through a number of slides on the Irish demographic structure from 1991 through to predictions for 2040 which starkly illustrated the reality of our ever-increasing older population.
“It’s over a third increase in older people. So this is a tidal wave that’s already with us. Our hospital colleagues, and our GP colleagues are already seeing this huge increase in older people and chronic disease, it goes through the whole system,” he said.
Such an increase is associated with a marked rise in the costs to the health service and Ireland’s health budget is set to come under increased cost pressures in the years to come with a projected cost rise of 30%. The medication costs for those over 65 on medical cards increases rapidly and with this segment growing fast, the question is, will we be able to cope with it, asked Dr Clarke.
General practice
Taking GP consultations alone, the ERSI has projected a increase of 20% by 2015 with a 33% rise expected by 2021. As there are around 20 million consultations in general practice annually, this will mean a rise to approximately 35 million consultations with a static GP workforce, said Dr Clarke.
“And just to put that number into context, 1.9 million consultations take place in outpatients departments every year,” he added
As the general population ages, so too does the GP workforce. Dr Clarke referenced the Competition Authority Report report of 2005, which showed that the average age of GPs at that time was 50-54. The recently published Medical Council Workforce Intelligence Report found that 929 GPs were aged 55 and over, a figure that represents one-third of the workforce.
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Not only are GPs getting older but those starting out in their careers are not committed to staying in Ireland.
Planning for the Future of Irish General Practice, an ICGP report published recently found that 60% of current trainees were still undecided as to whether they will emigrate, with 12.3% definitely planning to emigrate, and only 25% planning to definitely stay in Ireland.
“So this is a major problem brewing here. Stability of general practice, lack of structure, professional satisfaction, quality of life, and so on and so forth are all affecting this. So, that’s the background in terms of general practice, said Dr Clarke.
Conversely, he explained that in this same period of decline for GPs, the number of nurses per 1,000 population had risen in Ireland, something that could offer a solution to the chronic disease care burden in general practice. .
Chronic disease management
Referring to diabetes, heart failure, asthma, COPD, stroke and heart disease as the ‘big six’ in terms of chronic disease, Dr Clarke said these accounted for 80% of GP consultations and 60% of hospital bed days as well as two-thirds of emergency medical admissions to hospital.
“Most of the care of patients with chronic conditions should take place within the primary healthcare sector. This includes: diagnosis, treatment and rehabilitation of patients with chronic conditions; early detection, assessment and follow-up comprehensive medical treatment, and preventive activities including smoking cessation, dietary advice and support of patients’ self care,” he said.
It has been shown that integrated chronic disease care in the primary care setting works but not overnight. Deaths are prevented and illness reduced.
“Chronic disease management in general, based on the diabetes model structure, as a GP-supervised practice has delivered,” Dr Clarke added.
However while primary care management works, as already pointed out, the declining population of GPs posing the question as to who will provide the management. According to Dr Clarke the solution is “pretty obvious” and that is to “really bump up” the number of clinical nurse specialists and practice nurses.
“Practice nurses relate to this because GPs simply won’t have the time, and won’t have the capability to deliver the structured care required. It will have to be delivered by teams, and especially practice nurses. So GPs would look after particularly difficult cases and co-ordinating with the clinical nurse specialists on general care, so when we point the patients to the hospital, you’re just getting patients who really needed to go to the hospital,” said Dr Clarke.
GP perception of chronic disease management is mixed according to a recent report entitled A National Survey of Chronic Disease Management in Irish General Practice. Less than 10% felt that it ‘worked well’, the majority at over 60% thought that it was ‘good but needed significant change’, and 28% felt it was ‘completely wrong’.
“GPs don’t think that it works very well. Most think that it really has much that could be improved. But there’s a significant 28% of GPs who say that it’s completely wrong... So, there’s a lot of work to be done there,” he said.
In better news, this survey also found that the majority of GPs are using guidelines to manage diabetes, assist patients in setting and maintaining self-management goals and refer patients for education about diabetes.
However, two-thirds of the practices did not use a diabetic register and did not routine follow-up with patients between visits. And 80% of practices didn’t use tracking systems to remind patients of visits or flow charts to track critical elements of care. According to Dr Clarke these will have to change if we are to achieve better care.
His final message was that the 'future has arrived' and we need to act now. “Chronic disease will overwhelm services, unless we get a handle on them. GP retention, in terms of GP trainees, is crucial. And practice nurse and clinical nurse specialists need to be better utilised.
“As a country, we are capable of delivering the integrated care. We need to focus on increasing the numbers of practice nurses, this will be a massive component of chronic disease management in my opinion, and some work needs to be done to integrate the hospital and GP systems. It is all achievable but this needs to be taken seriously,” said Dr Clarke.
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