Professor Garry Courtney:

How do hospitals fit into GP-led primary care? We believe that the role of our hospitals is to support primary care, not the reverse. Our current hospital-centric system delivers excellent specialist care but cannot deliver cost-effective care for the tsunami of chronic disease and multi-morbidity that is strangling our health service. A total of 530,000 people are on waiting lists to see a specialist and up to 500 a day are on trolleys, which highlights the scale of the misalignment between demand and capacity. Clearly, capacity in our hospitals needs urgent attention. New thinking on OPD access is also needed, including better use of ICT and virtual clinics in chronic disease. A great example is the heart failure virtual clinic run by Professor Ken McDonald of St. Vincent's Hospital, which shows an 80% reduction in hospital referrals. We need to work with the clinical programmes, which are excellent examples of collaborative care pathways, developed between HSE, the royal colleges and GPs.

Our national manpower status is perilous, both in general practice and hospitals. Many of our young graduates - both doctors and nurses - are leaving. In secondary care, we are reliant on non-national junior doctors to run our hospitals and, without them, the system would collapse. There is also a shortage of consultants. In general practice, some 28% of GPs are aged over 60 and face retirement. We train only 176 GPs a year, yet require 250 just to stand still, given emigration and retirements. GP training numbers need to be increased by 100 and work must be done on retention of graduates. A total of 90% of GP trainees are female and most do not want full-time positions or practice responsibility until their families are older.

The committee’s plan for a ten-year consensus in health and a decisive shift towards primary care is welcome but there are specific challenges to be overcome. Building effective business relationships between secondary and primary care will be the key to success. In Carlow-Kilkenny, we have a tradition of engagement between GPs, hospital consultants and management, based on dialogue, respect, trust and innovation, which builds an integrated health system that works on solutions. This model can be scaled up with primary care division and State support. The emerging LICC process can improve the interface between primary and secondary and should be extended nationally. Ambulatory care should be supported through an acute floor that integrates horizontally with services in the hospital and vertically with GPs and the community. GP-led primary care, working in partnership with hospitals and community, is the best future of our health system. By working together we are stronger and patient care is enhanced. This is integrated care and this is the Carlow-Kilkenny model.