Dr. Pádraig McGarry:

On behalf of the IMO, I thank the Chairman and the committee for the invitation to discuss primary care expansion. Since the World Health Organization, WHO, Alma Ata Declaration of 1978, many countries have recognised the need to orientate health care towards GP-led care in the community, based on an extensive body of international research which shows that continuity of care and the patient-centred approach that is specific to the general practice model of care is associated with better health outcomes, equity of access, reduced inequalities in health, more appropriate utilisation of services and long-term cost-effectiveness.

Numerous recent studies have reaffirmed the value of general practice. For example, a 17 year study of more than 1,700 older patients found that continuity of care through attending the same general practitioner was associated with lower mortality. Continuity of care in general practice has also been linked to reduced probability of patient hospitalisation, an uptake in screening programs and immunisation, improved medicine use and adherence, and lower health care costs. Elements of high-quality general practice, including robust continuity of care, greater first contact access and use, more person-focused care over time, a greater available range of services provided when needed, and co-ordination of care are strongly linked with superior patient outcomes and lower health care costs. In particular, areas with greater general practitioner activity have been found to be associated with lower hospital activity, more co-ordinated care and lower health care costs. The efficiencies and cost savings delivered by investment in general practice were demonstrated by an analysis conducted by Rhode Island’s department of health that indicated that higher general practice utilisation rates are associated with decreased per person health care costs and improved patient outcomes.

At the same time the prevalence of chronic disease is expected to increase by between 4% and 5% per annum over the next ten years. Currently, care for patients with chronic conditions is fragmented, with the majority taking place in hospital settings at significant expense to the taxpayer. The current model for managing chronic disease is fragmented and is focused on the acute hospital system. That system is overburdened and underfunded, with emergency department, ED, overcrowding, intolerable waiting times for outpatient appointments and inequity of access. Acute services are now undertaking an enormous volume of work that could, if resourced properly, be managed in general practice. Such a move would ensure that care could be delivered to the patient in the community, outcomes would improve and, importantly, capacity in the acute services could be freed up to deal with cases of greater complexity. The Irish Medical Organisation, IMO, has been consistently calling for a shift in the model of care towards general practice and care in the community, with additional supports including maximising the use of practice nurses and equitable access to allied health care professionals in the community. The model of care must be GP-led to ensure continuity and a patient-centred approach, and to avoid duplication and further fragmentation of care.

In May 2017, the Oireachtas cross-party Committee on the Future of Healthcare published the Sláintecare report, laying out an ambitious ten-year plan for reform of the health care system. In line with international evidence, the cross-party group reached consensus on the need to reorientate care towards general practice and care in the community. The IMO has some concerns about the visitation rates, costings and timelines for implementation.

There are currently 666 GPs over the age of 60 who will be retiring in the next five to seven years, of which 244 GPs are over the age of 65 and are likely to retire in the next two years. With current difficulties in recruiting GPs, rural areas are likely to be most affected.

The HSE Health Service Planning Office estimates that with the introduction of the under-six GP visit card, demand for GP consultations in this population will have increased by 65.7% in 2017 and by 42.4% by 2022. Based on conservative estimates by the HSE National Doctors Training and Planning Office, by 2025 Ireland will need an additional 1,380 GPs to meet current demand, while an additional 2,055 GPs will be needed to expand free GP care to the entire population.

Cuts to general practice under the Financial Emergency Measures in the Public Interest Acts of up to 38% have had a significant impact on GPs' morale and their ability to recruit additional staff. A recent survey by the Irish College of General Practitioners highlights a number of causes of general practitioners’ dissatisfaction with their working conditions. Roughly half of all general practitioners rate their morale as either poor or very poor, three quarters report their stress levels to be either high or very high, and more than half of those who tried to recruit a sessional doctor or assistant during the past year were unable to do so.

Some 17% of newly qualified GPs work abroad, with many more planning to emigrate. A survey of GP trainees found that more than half are undecided as to whether they will remain in Ireland, one eighth are resolved to leave Ireland, and just a third plan on remaining to practise in Ireland.

There is no infrastructure in place to support multi-disciplinary team working. Waiting lists apply to allied health and social care services in the community, and many of these services are simply not available to patients outside the General Medical Service, GMS, regardless of their ability to pay.

The most recent national system of health accounts released, those for 2015, demonstrate that just 3.5% of public current expenditure on health is spent in general practice. By contrast, the United Kingdom’s National Health Service spends 8.1% of its budget on general practice, and has committed to increasing this proportion to 11% of its budget. In Australia this figure sits at approximately 6.4% of public current expenditure. Ireland is losing its newly qualified GPs to countries where the value of GP care is recognised, and where governments apportion a greater percentage of public spending to GP care.

Experience from other jurisdictions shows that in order to reap the benefits, the development of general practice and care in the community requires significant investment over time. Even if general practice was to be fully funded tomorrow, there is not enough capacity in general practice to deal with the predicted additional workload. The under-six contract brought in 240,000 additional patients. The Sláintecare report recommends that free GP care be extended to 500,000 additional patients per annum. As it is currently constituted, this will lead to waiting lists in general practice as demand will outstrip capacity. Additional supports for infrastructure and practice staff, specifically additional practice nurses, will be needed to allow GPs build up capacity. Consideration must also be given to supports for GP principals to hire additional GPs, as well as administrative support. Many practices will need to physically expand to cope with the additional workload and create capacity. This may require grants for extensions, additional rooms, etc. GPs must be able to access diagnostics and allied health and social care professionals on an equitable basis.

Same-day service and continuity of care are part of what makes Irish general practice work well. By increasing demand through making service available free at the point of use without also increasing capacity we threaten these very principles. It is important, therefore, that the impact of any measures is fully thought through, with a more detailed examination of the increased workload and capacity that will be required to ensure that care is delivered to the patients that need it. There is no point in removing one barrier to access in the form of cost if we only create another in the form of time.

In line with the IMO recommendations to the Oireachtas Committee on the Future of Healthcare, the IMO is calling on the Department of Health and the HSE to agree a strategy with the IMO for the development of general practice and GP-led care in the community over the coming decade. Priority should be given to negotiating a new GP contract with the IMO that is properly resourced and fit for purpose for a 21st century health service. This contract should focus on investment in evidence-based chronic disease management programmes for which GPs are already trained. The IMO would be pleased to discuss any aspect of our statement further with the committee.