Primary care yet to come of age

THE woman on the bus was blue in the face from all the talk about primary care.

“I’m bamboozled,” she told a captive audience on the 208. “Every newspaper I pick up, every radio station I turn on, it’s primary care, primary care, primary care. Does anyone even know what primary care means?”

It appeared no-one did. The woman hit the stop button to alight at her local church, where her best bet was divine inspiration.

After canvassing a few friends for their understanding of primary care, I found most none than wiser than the mystified traveller. “It’s another name for your GP, right?” said one. “No idea,” said another. “Life’s too short,” said a third. Only one made the honours grade. “Let me use an analogy,” she said. “When you enter mainstream education, your first port of call is primary school. This is where you get a good grounding in the basics. It meets your needs until you’re ready to move onto the next level. Primary care is the same. It is the first port of call for most patients and can meet the needs of most people.”

In other words, primary care is pre-hospital care, provided in the community by your GP, your social worker, the speech and language therapist, the physio, the podiatrist, the dentist, the public-health nurse — all those health professionals who, if properly resourced, have the potential to prevent the development of conditions which might later require more complex interventions, including hospitalisation.

So there it was; a reasonable explanation of what was meant by primary care. Which led me to the next question: What was the role of the primary care centre in the delivery of primary care?

Listening to the general debate, some seemed to think the two terms interchangeable, that primary care and primary care centres were synonymous or that general practice and primary care were one and the same thing. In search of greater clarity, I took myself off to Mallow Primary Healthcare Centre in North Cork, one of the largest primary care centres in the country, conceived during the boom and built at a cost of €25m.

MPHC is, according to the doctors who invested in it, the first centre to come on stream with a private leasing arrangement in place with the HSE. Eleven doctors got together to raise the finance under the banner of the Mallow Primary Care Development Group; nine have a 10% stake and the remaining two have 5% each. It’s one of the country’s more ambitious primary care centres. David Molony, one of the doctors who invested, admits the financial burden is huge. Tony Heffernan says the decision to build was made at a time when the world was “a very different place”.

HSE involvement was central to the project going ahead. The HSE came on board in 2006 as the key tenant and has a 25-year lease.

“We were the first child through with the [HSE] lease arrangement,” says Dr Molony.

It’s a fine-sized first child, big as a hospital and impeccably groomed. It’s home to three general practices — The Medical Centre, The Red Kettle Practice, and The Cork Road Practice — comprising of 21 GPs, all of whom, prior to the opening of MPHC in May 2010, were scattered in or around Mallow. In addition to the GPs, there is a “fourth practice”.

This consists of a range of privately run specialist services which most of us don’t have access to in our local surgery, including physiotherapy, an ultrasound diagnostic clinic, a warfarin clinic, a psoriasis clinic, a cardiac clinic, counselling and psychotherapy services, a diabetic clinic, a sleep clinic — the list goes on. It’s effectively a one-stop shop for patients, open to anyone willing and able to pay and unwilling to queue. For those who can’t afford private care, the HSE also provides services on-site, a number of which duplicate those offered by the fourth practice, the inevitable result of a two-tier healthcare system.

The doctors at MPHC are delighted with their new working environment, but disappointed it has not yet reached its potential. In line with the previous government’s 2001 primary care strategy, they had hoped, by now, to have a greatly expanded role.

The strategy saw primary care as the appropriate setting to meet 90%-95% of all health and personal social service needs. It talked about reallocating responsibility for services which are currently provided in specialist care settings. Chiefly, primary care was to have responsibility for management of chronic disease, by definition a generally incurable disease, such as diabetes or asthma, that lasts more than six months. About 80% of GP consultations are related to 18 chronic diseases and their complications. It makes sense to have them managed in the community, reducing the pressure on hospital beds. But GPs at MPHC say thatprimary care has not been resourced to let this happen to the extent to which it could be done. Dr Molony says that they have developed services on their own initiative rather than waiting for national funding, for example a diabetic clinic, supported by their own practices, and using drug company funds to procure a diabetic nurse specialist. They see more than 500 diabetic patients, and only a fraction are referred to Cork University Hospital.

This is the primary care strategy in action: Manage the diabetic, manage the asthmatic, manage depression properly, and the need for hospitalisation will reduce.

Harry Casey says they could also be doing more in the area of diagnostics.

“Probably one third of hospital referrals we make are for basic diagnostics,” said Dr Casey. “We have created an environment here where a lot more could be done, but we have no cover for public patients. They are entitled to free access in public hospitals and, as a result, the hospitals are jammed. If we had cover here, we could look after them.”

The doctors are disappointed with the attitude of private health insurers. Dr Molony says that while they will cover the cost of some procedures, they won’t pay a facility fee. These are the “sideroom fees” paid by insurers to hospitals to cover the cost of the rooms and facilities used. Dr Molony says he carries out a “good number” of procedures at MPHC, but more than 50% are done “almost at a loss”.

If they could get a facility fee, they could do a lot more. “For instance, you have people waiting in hospital queues to have sebaceous cysts removed that could readily be done in primary care,” says Dr Molony. “Many GPs have surgical training. I can only suspect the insurers are trying to keep everything in the hospitals.”

Dr Heffernan says if they had the facility fee, they could treat patients “closer to home at cheaper rates”.

“A fraction of the facility fee paid to hospitals could be paid to the GP for carrying out the same procedure, but the private health insurers haven’t seen the potential of primary care yet,” he says.

SO what of the patients using MPHC? One thousand pass through its doors every day. There are 25,000 registered patients. Lil Cunningham, 79, from Mallow town, is one of them.

“I’ve been a patient of Dr Molony’s for more than 20 years and I have no cause for complaint. He’s a brilliant doctor. But I have to say the new centre is fantastic. There’s no comparison with the old practice. It was far too small. This one has everything, the doctor, a pharmacy, great parking, great room.”

Lil reckons it’s a great development for Mallow. The building is spotless, there’s even a place to have a cup of tea, at Food Capers, where everything is freshly baked. But, mostly, Lil’s there because she gets good care.

“I had a very bad lung infection last Christmas, it lasted three months, but Dr Molony treated me so that I never had to go to hospital and I was very happy about that.”

Lil’s experience sums up the purpose of primary care: Keep it in the community if that’s where it can be treated. Don’t jam up the hospitals with needless referrals. Keep down healthcare costs. Dr Molony says that standard rates for a GP visit have not gone up since they moved to the premises: The fee is €50 for those without medical cards.

Marjorie Cronin, 78, from Doneraile, loves the fact that the new centre spares her a journey to Cork city.

“I had to have an ultrasound recently and, but for the new centre, I’d have had to go up to Cork. I also had to have a scan of the glands in my neck. That saved at least two trips to Cork.”

She thinks the new centre is “beautifully finished off”. She is not alone in her opinion; last year, it was named Ireland’s Best Healthcare Building at the Local Authority Members Awards. MPHC manager Conor Healy said they wanted it to be open, accessible, and friendly and it is certainly that. There’s a lot of clever design. The colour tones inside the front entrance to the building are warm and welcoming.

They become more clinical in colour and design as you move into the GPs’ surgeries and doctor treatment rooms. Skirting boards disappear to avoid dirt collection as part of infection control. Sinks have elbow-operated taps, eliminating the risk of hand contamination. Disposable curtains are clearly marked with the last date on which they were changed.

Waiting areas look out onto pretty courtyards. Each practice has its own reception area. This is what patients wanted, says Dr Heffernan.

“We consulted with people at the start of this journey, patients and patient groups, various stakeholders, and they came up with the positives and negatives of putting all our practices under one roof and one of the things that came out of that was they wanted to deal with the people they were used to dealing with. So each of the three practices has its own reception area with its own receptionist and administrative staff.”

The 70,000 sq ft building is spread over four levels, but is accessible at ground level from the first three floors. SouthDoc, the GP co-op out-of-hours service, occupies part of the building and has its own entrance. The HSE occupies most of the second floor and numbers among its services a community mental health team.

Dr Molony says this is particularly welcome, leading to greater integration of services and feeding into efforts to reduce the stigma of poor mental health.

“It’s important patients with mental health problems can come through the same doors as everyone else. It is very much part of what GPs deal with on a day-to-day basis,” Dr Molony says.

MPHC is busy proving its potential. Diagnostics costings show that an ultrasound can be done within seven days at a cost of €110, and a report sent to the GP within 24 hours. No visits to an out-patient department are required. The same analysis shows a current hospital-based ultrasound with a waiting time of 9-36 weeks. Total cost: €620, including the cost of the consultant, the cost of the report, and the cost of a return visit to outpatients after the report comes back. Total saving per ultrasound examination carried out in a primary care centre: €510, and no out-patient visits.

MPHC has also demonstrated significant savings through its own retinopathy screening programme. This is an annual test for diabetics to check if their eyesight has deteriorated due to a condition known as diabetic retinopathy. Untreated diabetic retinopathy is one of the most common causes of blindness in the working-age population. According to MPHC costings, a retinopathy test using a retinal camera can be carried out on the premises at a cost of €44, no waiting required. This compares with a cost of €260 for a hospital-based consultant check for retinopathy. A total of 500 retinopathy tests were done at MPHC, at a cost €22,000. This compares with €130,000 for a consultant to see 500 patients at a hospital out-patient department. MPHC is making a good business case for funding some of its services.

Next month, the centre will host the second National Primary Care conference. It’s theme — Primary Care Centre Stage: better outcomes with scarce resources — could hardly be more apt.

Research and education

Tony Heffernan says MPHC is deeply committed to research and education. It is one of four centres in Munster where medical students train, coming from University College Cork and the University of Limerick graduate medical school.

UCC nursing students carry out training placements at MPHC on an ongoing basis. It also has a dedicated education centre, the READ (Research, Education, Audit, and Development) Centre. Dr Heffernan says that they continuously research and audit all the processes.

The primary-care strategy recognised the importance of IT in promoting its model of health professionals working in primary-care teams. It cannot work without foolproof systems for information-sharing and communication. David Molony says that their practice is fully computerised, but that hospitals are hampered because they remain heavily paper-based. “The technology is there, but there has to be a willingness to look at it and put it in place,” he says. Because the technology is there, there is no need, he says, for all members of a primary care team to be grouped under a single roof. Virtual teams can also work, he says, but the strategy acknowledges that primary care team members should ideally be located on the same site.

MPHC was opened in 2010, less than decade after then health minister Micheál Martin said his primary care strategy would “provide a blueprint for the planning and development of primary care over the next 10 years”.

The doctors at MPHC say there wasn’t a medic who didn’t buy into his vision.

“That strategy is 100% right, but the rollout just hasn’t happened. People have been locked into silos. A lot of people in the Department of Health made this separation between hospitals and primary care,” Dr Molony says, instead of seeing that the successful operation of one would fuel better outcomes for the other.



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