The Sláintecare report from the Oireachtas Committee on the Future of Healthcare outlines a 10-year plan for the Irish health services.¹ For the first time, an official report has recognised that the service we have now, one of the most expensive in Europe, is neither fit for purpose nor sustainable. The conclusions of the report are at once an immense opportunity for Irish GPs, and an enormous challenge. Whether our health system is reformed or not will largely depend on whether they choose to embrace their conclusions.

The report was produced by a cross-party group of TDs led by Róisín Shortall. The Committee was tasked with producing a blueprint for a more sustainable and affordable healthcare system re-oriented towards primary care, with universal access for all. The key health system problems it targets are:

• Irish healthcare is very expensive, and a very high proportion of the costs are paid for either by private insurance, or by out-of-pocket payments

• The healthcare system is very focused on acute hospitals and other large institutions, with limited access to even the most basic facilities outside hospitals

• The health of the Irish population is reasonable, but many measures of health system performance are not; in particular, waiting times for non-emergency care for public patients are extremely long.

There is also the wider issue of significant gaps in health between richer and poorer people in Ireland. While health and social care provision alone can have a only a moderate impact on these inequalities, the report shows evidence to suggest that the current structure of Irish healthcare is making these inequalities worse.

The values behind the report are well summarised in a quote from the 2006 EU Council conclusions on common values and principles in European Union Health Systems: “The overarching values of universality, access to good quality care, equity, and solidarity… universality means that no-one is barred access to healthcare; solidarity is closely linked to the financial arrangement of our national health systems and the need to ensure accessibility to all; equity relates to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay.”²

The report’s recommendations can be divided into three main areas:

Single-tier health service

The report argues for a single-tier health service, with free, or close to free, access to health and social care services. It debates the merits of a tax-funded system, versus a compulsory single payer insurance system, and comes down on the side of a largely tax-funded system. The recommendations intend to sharply reduce user fees for services, including Drug Payment Scheme levels, fees for medical card users, and fees for hospital care. Under the recommendations, GP visit fees would remain in place, but are likely to be closer to €5 than the current €50 or so per visit.

Integrated care essential

The report states that integrated care is essential if the Irish health service is to have a future. This means patient-centred healthcare, delivered as part of a well-organised health service, at the lowest appropriate level of complexity; a service that makes comprehensive care pathways both accessible to patients and deliverable by service providers; where there is communication and information support, decision-making, governance and accountability; and where patients’ needs come first in driving safety, quality and coordination of care. This care runs from self-care to tertiary care services, and includes social care, which is another major step forward, and palliative care.

This will require a decisive shift of care and resources to primary care, with a strong focus on the Healthy Ireland agenda, as well as strong clinical governance and accountability throughout the system. It proposes a further group of managers be appointed to deliver this, suggesting that HSE establishes Integrated Care Regional Organisations, to work with the existing Community Health Organisations (CHOs) and the hospital groups. I don’t agree, as I think this should be the key responsibility of the CHOs.

New model of healthcare funding

To pay for all of this, a new model of healthcare funding will be needed. The report proposes completely splitting private from public healthcare. While most of the discussion here is around hospital care, there are likely to be implications for primary care too, in particular for private patients in general practice, and private services providing access to diagnostics for a fee.

It suggests a large one-off increase in capital expenditure, and a front-loaded rise in healthcare spending. Given the already high costs of healthcare in Ireland, the recommendations on funding have been criticised, but I see no way around both a significant extra capital investment, and a rise in day-to-day spending to allow the development of new models of care. It is a common experience that development of new health service models requires both continuing funding for the existing service and some extra funding to support the move from the old pattern of service delivery to the new.

More care in the community

The report repeatedly urges that much more care be delivered in the community, either by primary care or community care, but is less specific about who should do this. It calls for a significant investment to make a wide range of routine diagnostics readily and freely available to GPs’ patients, without hospital referral. It calls for a large increase in the number of GPs, and recognises that training GPs takes time. It strongly advocates for the Carlow-Kilkenny model of integrated care as an exemplar for GPs and acute hospitals working together. It also urges a large increase in mental health staffing and services in the community.

One core element of the recommendations is that care be delivered at the lowest level of complexity. This includes much more support for self-care, more care delivered by pharmacists, nurses, and other community-based staff. Ironically, for a report urging a move to a less hospital-centred system, there is still a heavy focus on acute hospitals.

Importance of GP contract 

There is a very brief mention of GP practice staffing, taken from a 2001 report. The importance of the GP contract negotiations is acknowledged in encouraging GPs to work differently, but little detail is given. There is a strong emphasis on clinical governance and a high level of accountability for clinical care.

One of my concerns about the report is the proposal to set up a range of new organisations to implement integrated care, and an overall implementation office to steer the change process. I do not believe this is a solution. Broken organisations cannot be fixed by splinting them with other organisations; rather, the root cause of the poor delivery needs to be addressed. To be fair to the HSE, its delivery has improved over the past three years, and it is possible that it is now grappling with its problems.

Opportunities and risks

Overall, this blueprint for change represents a huge opportunity for general practice, but there are risks. If GPs are willing to work differently, and to take a lead in the delivery of care in the community, there are no limits to how far the speciality might go. If not, GPs may well end up as glorified state medical officers, part of larger managed care systems led by hospital groups.

What would effective GP practice look like? In Ireland we tend to look to whatever the English NHS was doing 10 years ago, and follow that. This would be a major blunder. We need to learn from other systems, especially about the very modest benefits of scale in general practice. Speaking as a non-GP, I suspect that current models of GP practice are not sustainable. 

Many people do not want to run small businesses. As a result we are seeing the rapid expansion of GP chains in wealthier urban areas, sometimes with a high turnover of staff, and increasing numbers of vacancies on GMS lists, especially in rural areas. Many poorer urban areas are short of GPs, and many active GPs are coming up to retirement. We also know that hospital groups are eyeing the provision of more primary care services.

One model is to retain a partnership structure, where policies are set, and clinical accountability rests, with a small number of trained GPs, and something like three to five partners becomes the new norm. These practices could be built from salaried GPs, or the existing model, or a mixed GP payment system, and would be large enough to provide holiday cover internally. Such a group would have a practice manager, six to ten nurses, and might share a psychologist, a physiotherapist, or other specialised staff with other groups. 

Most nursing staff would be clinical nurse specialists, or advanced nurse practitioners in primary care, and with prescribing authority. Staff would be on HSE salary scales, with pension rights, and groups would use shared services from the HSE for various purposes. Ready access to diagnostics and other supports would be provided within the local primary care centre. 

Crucially, full clinical governance responsibility, for themselves and all other staff, rests with the GPs in the group, and management responsibility for staff lies with the practice manager. This model would be a huge change for Irish general practice. It could not apply everywhere, but it would preserve rapid access to GP care and continuity of personal care which are major benefits of our system. Issues to deal with include the financial basis for the new model, the value of existing practices, and securing the financial future of older GPs. None of these issues is insurmountable.

Given goodwill and imagination, Irish general practice could have a very bright future. The current GP contract negotiations, it has been suggested to me, are working on tweaks to the existing contract. If this is so, then I would be much less optimistic. Only bold and significant change, with substantial investment, offers a future for this critical piece of the Irish healthcare system. 

References

1. Committee on the Future of Healthcare. 2017. ‘Sláintecare Report’. Dublin, Ireland: Houses of the Oireachtas. http://data.oireachtas.ie/ie/oireachtas/committee/dail/32/committee_on_the_future_of_healthcare/
2. OJEU (2006/C 146/01) page 2. Accessible on http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52006XG0622(01)