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Introduction
I am delighted to join you this morning to officially open your conference and I would like to thank Chris Goodey for the invitation to attend.
Today’s event, following on from the success of your inaugural conference last year, has a particularly relevant and thought-provoking theme - “Defining Primary Care in the 21st Century”.
Given the array of national and international stakeholders attending, I have no doubt that the speakers, panel discussions and workshops will lend themselves towards healthy and robust debates on the role and future of primary care.
For me, the theme reflects a principle I hold deeply. I’m sure many of you have heard me say it before but I’ll say it again – making the decisive shift of the heath service to primary care in order to deliver better care close to home in communities across the country is paramount. I want patients to have access to safe and clinically effective treatments early, as close to their home as possible and at the lowest level of complexity. I don’t want to just talk about making this decisive shift; I want to make it a reality.
Primary Care Policy
As you know better than me, we have been talking about this for long enough. Fifteen years on from the 2001 Primary Care Strategy, many of its core features are still valid and its overall vision for an enhanced primary care sector holds true. That Strategy sought to enable primary care to develop the capacity to meet challenges - such as ageing of the population, ensuring earlier hospital discharge, care in appropriate settings as well as the opportunities afforded through modern information and communications technology.
The key challenge remains how to translate an internationally validated approach to the delivery of primary care into the specific professional, organisational policy and resource context in Ireland.
The philosophy of primary care goes beyond the realm of healthcare and requires inter-sectoral linkages between health and social policies. Countries with a strong primary care sector have demonstrably better health outcomes, greater equity, lower mortality rates and lower overall costs of healthcare.
My Department conducted a desktop review of international experience and developments in primary care in the last 11 to 16 years, together with the experience of the implementation of primary care policy in Ireland over that time. It highlighted that there is not cause for a major deviation from the nature of the service that should constitute primary care or the anticipated benefits to health and wellbeing, patient experience and outcomes, and to the wider health system.
Rather, it indicated that a top-to-bottom, system-wide and integrated commitment to policy and implementation is needed if the ambition of a health service that is truly grounded in a primary care service, centered on the needs of individuals, families and communities, is to be achieved.
Achievements
We need to be fully cognisant that augmenting primary care services is central to any successful strategy to address healthcare need and promote population health. Let me make it clear, however, I do not, for one minute, take lightly the developments that have taken place in primary care over the years and the commitment of those working in this area.
We have seen the extension of eligibility for GP cards to under-6s and over-70s, the development of the Diabetes Cycle-of-Care and on-going investment in the physical infrastructure for primary care. Quite significant investment has also been made in the development of primary care capacity, particularly in the therapy area. I am aware that work is on-going in the HSE on developing and delivering new models of care for therapy services.
We have also seen initiatives to support the delivery of care closer to home, which I would like to see further developed. These measures, which also serve to alleviate the pressures on our Emergency Departments - and the overall acute hospital sector - include:
Access to GP Out of Hours Services
Enhanced Chronic Disease programmes
Enhanced diagnostic programmes
Access to Minor Surgery
Access to Community Intervention Teams and Outpatient Parenteral Antimicrobial Therapy (OPAT) and
Access to Aids and Appliances
All-Party Oireachtas Committee
It was obvious to me prior to my becoming the Minister for Health some 10 months ago – and my conviction has only grown in strength since I took up office – that meeting the rightful demand of our citizens for a better health service required a new approach from politicians.
We need a single, long-term vision for the future of healthcare in Ireland. That means a long-term vision that is agreed by political, in fact societal, consensus and that will not change with a change in Government. A single, long-term vision that delivers on the goal of universal healthcare.
This was recognised in the Programme for Partnership Government and the Committee on the Future of Health Care, which was established in June 2016 and is chaired by Deputy Róisín Shortall, is considering issues such as a long-term vision for health policy, the implications of demand projections, a preferred model of care, and how this can be achieved and the associated funding models.
The Committee has been holding meetings and receiving submissions from the public and stakeholders and I met with them myself last week. Importantly, the Committee will make recommendations to guide us on the journey to universal healthcare. Primary care must and will be a key feature and I await with great interest the outcome of the Committee’s deliberations.
Chronic Disease Management
We are facing demographic and epidemiological challenges that are not uncommon to the vast majority of developed economies. Health systems and policies didn’t keep up with the dramatic changes in medicine in the latter half of the twentieth century. Diseases such as TB or polio, which consumed a large share of healthcare resources, were effectively defeated through a combination of vaccination and antibiotics. More recently, the investment in new medicines is helping to cure Hepatitis C, something that was once unthinkable.
Today, the great challenge is the management of chronic disease which, in some respects, is simply a feature of living longer. However, in many cases the onset of disease is influenced by lifestyle factors including diet, exercise, smoking and alcohol consumption. Because we are dealing with diseases that are managed rather than being cured, we now need a far greater emphasis on continuous care, as opposed to the traditional episodic care provision.
The challenge we face is to develop a new model of care, which is better suited to the needs of our population, now, and in the future. We need our hospitals to work more effectively, we need to develop primary and community care, and we need all components of the system to work in a better, more integrated and coordinated way.
Changing Model of Care
Many of the necessary features of the new model of care are already apparent and some are already being put in place.
The Healthy Ireland agenda plays a pivotal role given that relationship between chronic disease and lifestyle. While progress has been made on implementing our strategic approach in, for example, the areas of healthier diets and taking more exercise, more is required, including measures targeted at discouraging harmful levels of alcohol consumption.
There are a suite of measures contained in the Public Health (Alcohol) Bill which I consider to be a proportionate response to addressing the harms caused by the misuse of alcohol and to bring about a cultural shift in our attitude to alcohol.
Given the continuous nature of chronic disease, regular and ongoing management of those affected must be in place. It must begin with better information and self-management, but must also be provided and supported to a far greater extent through primary and community care.
Comprehensive Primary Care
As we seek to make the decisive shift to the provision of more care in the primary and community sectors, we must consider the challenges that experience has shown us we are likely to encounter.
Achieving better integrated services will, undoubtedly, require a high level of team-working across diverse professions. The challenge that is posed in achieving this is how to integrate different employment and contractual relationships, priorities, cultures and approaches. For example, experience has shown that it has not always been easy to combine the efforts of salaried HSE staff and GPs paid through capitation for medical card holders and fee per visit for others.
Furthermore, whilst we have delivered improved primary care facilities and we now have examples of very successful Primary Care Centres, we have, nonetheless, faced difficulties in some areas with GPs locating in such centres.
In addition, the provision of a comprehensive primary care service is also challenged by the issues of coverage and eligibility. We must, therefore, consider how we can address issues such as chronic disease management and hospital avoidance when the State’s financial support is predominantly concentrated on the 45% of the national population currently with free access to GP services under Universal GP Care and the GMS Scheme.
While these challenges are closely related to our existing organisational, contractual and eligibility arrangements, all health services seeking to promote primary care face the twin challenges of achieving successful team-based, multi-disciplinary working and enhancing the status of primary care professionals within the overall health service.
I understand that the University of Limerick recently concluded a Health Research Board funded project “Primary Care Reform in Ireland”, the object of which was to evaluate the reform processes relating to the development of Primary Care Teams. This project looked at healthcare professionals’ perceptions of progress with Primary Care Team implementation and what innovations have developed in primary care settings and their effectiveness. I look forward to reviewing the findings of this project and how they could feed in to a strengthened primary care service.
Over the next ten years we will have to expand the scope of our ambitions about what can and should be delivered in the community and primary care setting. This will involve more investment in personnel, buildings, diagnostics, and training, as well as expanding the scope of eligibility for primary care services on a phased and prioritised basis, taking account of resources and available capacity within primary care.
It is important to highlight, however, that whilst much more investment is needed, significant investment, in particular in relation to Primary Care Centres, continues to be put in place. Building on the 99 centres already operational, a further two centres are expected to be operational in the near future. There are 37 locations where Primary Care infrastructure is under construction or at advanced planning and a further 47 locations are at preliminary stages of development. Taking account of the above, 17 centres are expected to open in 2017 and 11 in 2018.
A major focus for the HSE is greater access to diagnostics. The HSE has developed a service whereby a GP can refer medical card and GP visit card adult patients for ultrasound scans. Patients deemed to be urgent are seen within 5 working days and routine patients are seen within 10 working days. This service is currently available in 9 Primary Care Centres and the Cork Affidea Site. I understand the plan is to continue to improve GP access to ultrasound in other areas of the country.
The HSE has previously indicated that the onward referral rate to a hospital setting for further radiological or medical investigations is approximately 15-20%.
This low onward referral rate demonstrates the success of the initiative and highlights the effectiveness of having direct access to ultrasound available for GPs and is further relieving pressure on hospital services and decreasing waiting lists.
The role of ICT in the delivery of health services cannot be overstated. In the context of patient safety, it is critical to have the right information about the right patient in the right place and at the right time.
Investment in ICT such as telehealth and telemedicine solutions can enable reconfiguration of services across Acute, Community and Primary Care sectors and the opportunity to deliver a more integrated service to patients irrespective of where the patient may be. Capital funding for healthcare ICT has increased but I do acknowledge that more needs to be invested in the coming years so that healthcare can invest in technology and reap the benefits in a comparable way to other sectors. I see that one of the workshops this afternoon is on the “Role of Technology in Primary Care” and I have no doubt the progress we are making on ehealth programme projects which are using technology to improve our health services will be discussed.
New GP Contract
As you know, we are at the early stages of negotiation of a new contract for GPs. I am committed to ensuring that patients throughout the country continue to have access to GP services, and that general practice is sustainable in all areas into the future. It is imperative general practice remains an attractive career option for newly-qualified GPs.
As such, the aim is to develop a new modern GP services contract which will incorporate a range of standard and enhanced services to be delivered. It is also important to continue the development of GP capacity in order to ensure that the future manpower needs of general practice can be met.
The new GP contract is by no means the only element of the transformation that we have to effect. My Department recently launched a consultation paper on the future development of community nursing which proposes a model of care that offers the individual, family and community a range of choices.
We are also undertaking a significant programme of work in the area of home care. We will launch a public consultation process in the coming months to allow those who have views on this issue to have their say, including older people themselves and their families.
Conclusion
As I know you have a full programme today, I will conclude by reaffirming the Government’s absolute commitment to the goal of universal healthcare and its steadfast support of the decisive shift to primary care.
We are all in agreement here and we have a shared priority – the delivery of enhanced primary care in every community – a primary care service that is fit for the 21st Century. Your conference today will contribute to the important debate of how we can achieve this shared vision.
Once again, my thanks to the Primary Care Partnership for the invitation and my best wishes to all of you as you participate over the next two days.