Dr. Ronan Fawsitt:

We are used to delay in the health service so it is fine. I thank the committee for inviting us today. We are two front-line clinicians based in Carlow-Kilkenny. We are not academics or health economists but we have learned what works. We have also seen what is possible when GPs and hospitals work together. We are not representing any organisation in this submission today but reflecting our own learning and experience gained over nearly three decades of local engagement. We support the committee's vision to transform the health service with a ten-year plan that is agreed by stakeholders and the State. We believe that in this age of digital health new thinking, new care pathways and new relationships between primary and secondary care are needed. Most of all it requires more joined-up thinking and activity in health.

Throughout the country our hospitals, community services and GPs are struggling with increasing demand, finite resources, reduced capacity, fragmented care, an ageing population and the growing burden of chronic disease and multi-morbidity. Our manpower crisis compounds the problem and there has been an absence of confidence and direction in our disconnected health service. Relationships between primary care and secondary care are strained in most areas. The financial emergency measures in the public interest, FEMPI, legislation cuts which took 38% of State funding away from practices over five years were applied disproportionately to general practice leaving it currently unable to take on new commitments without new resources. While hospital budget cuts were less severe, the combination of bed closures, limited manpower and service cuts have also left our hospitals unable to cope with increasing demand. It is a perfect storm for the health service and for patient care. We cannot continue like this. New thinking is needed.

We come from Carlow–Kilkenny where we have had new thinking. We are used to it. There is a 20-year history of engagement between GPs and hospitals, much involving the ICGP-St Luke’s liaison committee. This led to integrated thinking and improved patient flow in Carlow-Kilkenny. We call it a hospital without walls as GPs have very strong relationships with the hospital and are involved in all levels of service development and governance.

Over recent years, given all the challenges, we recognised the need to work more closely. We formalised and then structured this engagement by scheduling monthly business meetings between GPs, consultants, hospital management, CHO partners, mental health, public health and pharmacy colleagues. These meetings attract 20 to 30 doctors a month. It is a forum that builds relationships, encourages ideas and agrees change. It works through contact, respect, trust and innovation. Everyone may attend and everyone is equal.

The outcomes of this integrated activity in Carlow-Kilkenny has created a culture of GP-hospital-community engagement and has led to many local initiatives that have scaled. Caredoc, one of the earliest GP co-ops, began in 1999. The first acute medical assessment unit in Ireland was opened in 2000, which allows direct GP access. We call it streaming. The first acute paediatric assessment unit with direct GP access was opened in 2002. The first acute gynaecology assessment unit with direct GP access opened in 2005. The first GP-led community intervention team, CIT, which brings hospitals into the home, was formed in 2009. A new surgical assessment unit with direct GP access opened in 2014. Other recent service developments include new services in heart failure in 2014, acute arthritis in 2015 and a GP-led gynaecology clinic led by local GP, Dr. Eluned Lawlor, in 2016. The first purpose-built integrated ambulatory care centre in Ireland using an acute floor was opened fully in 2016, again with direct GP access. The concept of an acute floor with GP streaming is a proven mechanism that reduces admissions, shortens length of stay, and helps keep patients at home and not in emergency departments, EDs, or on outpatient department, OPD, waiting lists.

The Carlow-Kilkenny model has now been adapted as a local integrated care committee, LICC, by the Irish College of General Practitioners, the Ireland East hospital group and the primary care division of the HSE as a mechanism in other areas for local engagement and integration between primary and secondary care. The LICC is a bottom-up approach that is supported from the top. This roll-out is now being supported nationally by the primary care division of the HSE. There are a number of LICCs now active in the Ireland East hospital group, including Loughlinstown, Mullingar and Wexford. The Ireland East hospital group has been hugely supportive of this integration with primary care and it considers alignment with GPs and CHOs as a key strategic priority. The Ireland East hospital group recognises that an important role of effective LICCs in a new health system will be to help shift chronic care incrementally from hospitals to primary care in an agreed manner and with the correct resources to deliver benefits for patients. This will ease the burden on hospitals and reduce the cost to the State by supporting GP-led primary care.

We need to take five steps for success on the journey towards GP-led primary care in Ireland. First, we need a culture change towards more engagement between GPs and hospitals who need to work together locally in partnership with management, hospital and community, as equals in care. This LICC engagement process should be costed and funded by the State. Second, we need to move more care out of hospitals and into the community in an agreed and funded manner. The Primary Care Surgical Association is one successful example. GP-led primary care, working through enhanced primary care teams and supported by secondary care, can provide other models of community-based care. Third, we need to resource and strengthen the infrastructure of general practice by increasing the numbers of GPs, practice nurses and other health care staff to deliver these new packages of care. An end-of-life care package should be among the first. A new GP contract that deals with chronic disease is also critical.

Fourth, we need better flow for patients through the health system. Ambulatory care using an acute floor with GP streaming is the future for acute hospital medicine. Scheduled care, including OPD and day care, needs a 21st century model using a shared EHR, ICT, virtual clinics and new care pathways, but GPs are central to these developments. Fifth, we need the political and legislative certainty of ring-fenced funding to allow transformation of health care over an agreed period. This is critical. Clinician leadership and innovation should be supported locally and allowed to scale where there is success. There will be benefits to the State from efficiencies, savings, confidence and a healthier population and workforce. The transitional funding for development of GP-led primary care should not come from hospital budgets. The eventual funding model for the new State health system should be determined only when we have the correct care and treatment model agreed by all stakeholders and we are clear on the workload and costs.

Regardless of the funding model, general practice needs to be at the heart of the new health system. General practice and GP-led primary care can deliver comprehensive, co-ordinated, quality care that is accessible to patients and close to their homes. In an age of multi-morbidity and medical complexity, only the "generalist" GP can deliver appropriate care to this group of people in a cost efficient manner. However, the role of the generalist GP needs to be standardised. We ask the committee to advocate the Farmleigh principles of GP-led primary care, which I outlined in an earlier submission. They clarify the role. These principles were developed by Professor Tom O’Dowd of Trinity College Dublin in consensus with all stakeholders in 2015, using the TCD Chatham House Group, now known as Tomorrow’s Health. The principles articulate clearly what work is done in general practice and who is accountable. It should be central to any new GP contract and a foundation stone for integrated care with our hospital partners.

Professor Courtney will take over from here.