Dr. Brian Osborne:

With the permission of the Chair, Dr. O'Brien and I will share responsibility for delivering the presentation. The Irish College of General Practitioners, ICGP, thanks the Chair and members of the Joint Committee on the Future of Mental Health Care for the invitation to reflect on the development of general practitioner led primary care as it relates to mental health. The ICGP is a professional body for general practice, with more than 4,000 members and associates and 690 general practitioner trainees.

General practitioners are at the heart of the health system. Every day, thousands of people all over the country see their family doctor without any waiting time and receive quality attention and care. Between one quarter and one third of such consultations include a mental health component.

Over 90% of mental health care takes place in a general practice setting. To ensure we can continue to provide that cradle-to-grave service for a growing population with more challenging conditions, and address our retention and manpower crisis, we urgently need to commit to greater resources and a new contract to further develop GP-led primary care.

A large proportion of these daily interactions are driven by the mental health needs of people attending. Maintaining quick and easy access for people to generalist health care professionals in the community must be an overarching objective in the future expansion of primary care, enabling people who are well known to each other in a personal sense to engage collaboratively to address the needs of people attending, in their own communities, and to assist in building their resilience. As general practice services are not associated with any particular health condition, stigma is reduced when seeking mental health care from a general practice team, making this level of care far more acceptable and accessible for people and their families.

The work of general practice is prevention and earlier intervention. Our values relate to lifelong personal medical care, wherein people choose and are enabled to attend a doctor or nurse who they know well, and who knows them and their circumstances well, and where mutual confidence is to the fore down the years and across the generations.

In this submission, we demonstrate what the expansion of GP-led primary care means with respect to mental health, what the challenges are, and what our legislators need to do to ensure general practitioners can continue to be at the heart of a reformed health service. It is the view of the Irish College of General Practitioners, ICGP, that unless adequate capacity is built in GP-led primary care, the remainder of primary care, the secondary care sector, and the broader health system will never function safely, efficiently or effectively. Collectively, we need to undertake a realignment from a hospital-focused system to a more balanced system, where much more care is delivered in communities.

In addition to grave difficulties in secondary care as a result of chronic underfunding of GP-led primary care, there are separate intractable difficulties regarding the way secondary care is delivered in the Irish health system, and it is not the task of primary care to fix these. These difficulties in secondary care relate to an over-reliance on non-consultant hospital doctors, NCHDs, working exclusively with public patients, and a continued failure of secondary care to embrace electronic medical records and administration. Poor communication and a lack of integration between general practice teams, primary care health professionals and secondary care lead to reduced efficiency and effectiveness of the whole health system.

Protracted and grave difficulties are evident in critical bottlenecks in emergency departments, waiting times for most public hospital services, sub-optimal health care outcomes, perceived and actual gross inequalities access, and in well-identified system risks arising from poor continuity of care, which will all continue as the inevitable consequences of a hospital-centric health system, where decades of systematic under-resourcing of GP-led primary care are also clearly evident.

Specialist services in a hospital-centric model will continue to be unable to safely or effectively address present volumes of clinical workload. Much of this workload is best addressed in the community setting, delivered by teams of GPs and practice nurses working in a generalist service, based in practices adequately supported by administrative staff and allied health professionals, with access to focused educational supports, so that more of the mental health care needs of most people can be addressed in the community, closest to where people live and at the most

appropriate levels of cost and complexity. Timely and equitable access to essential and valued specialist care, where necessary, is an integral part of developing an effective overall system.

There is strong international consensus around developing a health system based on strong GP-led primary care. Development of universal access to strong primary care delivers substantial benefits to all citizens, and must now be considered relatively inexpensive, in terms of whole-system health care costs. With respect to mental health, increasing the numbers of GPs and practice nurses, and training and retaining them, is important so that there is adequate capacity to meet the rapidly evolving demand from a growing population. The importance of easy access for people to GPs as point of first contact and early intervention is broadly agreed internationally.

In recent years the ICGP recognised that over-medicalisation has become more apparent in the health system, characterised by a continued and almost exclusive focus on technical, hospital-based medical care. We also question the extent to which the Irish health system supports talking therapy. We accept that we spend over €1 billion on drugs, a large proportion of which relates to psychotropic drugs, when we spend less than €10 million per annum on services such as counselling in primary care. We rely on a GP-led primary care sector which is seriously understaffed.

Initial steps towards achieving a health system based on GP-led primary care must be the immediate reversal of resource cuts introduced under the financial emergency measures in the public interest, FEMPI, legislation, and the replacement of the present general medical services, GMS, contract with one which addresses the needs of people who attend GPs and their practice teams for ongoing medical care.

These two issues, FEMPI and the GMS contract, are constantly to the fore in communications between our college and the GPs who are college members, GP trainees and practice nurse colleagues. GP-led primary care is at present delivered by approximately 3,700 GPs and 1,700 practice nurses. In health systems which are considered more effective than ours, such as those of Scotland, Canada, the Netherlands, Australia and Denmark, there are more GPs and practice nurses who work uniquely with a truly generalist and holistic approach.

In Ireland, at present we have approximately 64 GPs per 100,000 population. They are unevenly distributed, with fewer than 40 per 100,000 in three counties. In Scotland and Canada, the number is between 90 and 100 GPs, with an effective ratio of 0.8:1 between GPs and practice nurses. The view of the ICGP is that we need to plan for a population of 5 million, with corresponding increases in GP and practice nurse numbers. The acute and outstanding needs of rural practice, and practice in deprived areas, must be supported appropriately and urgently, with serious thought given to geographical and deprivation weightings in funding. GP-led primary care is a key support throughout the lives of Irish citizens, supporting them from before birth to end-of-life care and grieving. Every day, people who are troubled by mental health problems attend GP-led teams, with large volumes of care provided by GPs, through mild and moderately severe spectrum mental health conditions, including unipolar and bipolar affective disorders, suicidality, obsessive-compulsive disorders, acute anxiety, phobias, post-traumatic stress disorder, personality disorders, the full spectrum of addiction disorders, methadone maintenance and the psychoses and for ongoing support over years in body image disorders, dementia and post-partum depression. In caring for people suffering from these conditions, general practice has done so without the levels of inequality regrettably associated with most secondary care services. However, during the decade from 2007 to 2017, GP-led primary care has been allowed to weaken to an alarming extent.