Dr. Brendan O'Shea:

We are making a case for stronger primary care. Why is generalist care important? Generalist care is important because people are complex and they rarely present with single issues in real life. Generalists deal with the totality of problems people experience and present with, addressing them with regard to their physical, psychological, social and existential context.

If people are funnelled into specialised services for common problems they will quickly become frustrated with dead ends at every step, and such a system grinds to a halt around these dead ends. It is the view of the ICGP that this phenomenon is substantially at the heart of the phenomenon of over 650,000 people on public waiting lists at present.

Failure to grasp this reality results in serious problems in responding comprehensively to the range of problems people with their health. We strongly recommend that legislators recognise the difference between generalist and specialised care, and take effective steps to increase capacity in generalist primary care in communities, as opposed to our historic focus on specialised secondary care.

I will now outline the connection between generalist care and mental health. The ICGP is at present committed to collaborating with the HSE, and all other relevant stakeholders, in assisting in the development of better care for people with long-term illnesses. In the long term, the ICGP supports free primary care at point of access, fully resourced in communities, as critical for success in this objective. We recognise this as an essential, socially redistributive undertaking in our unequal health system.

The ICGP recognises the importance of mental health as a key prognosticator across the range of all common long-term illnesses, and this, together with more effective end-of-life planning, are areas which we have identified as key points in reorientating our historic focus on specialist-orientated hospital care. The people we care for with diabetes and heart failure have better outcomes if underlying depression and anxiety are detected and treated earlier and more systematically. This takes more time on the part of GPs and practice nurses to deliver. However, GP teams are currently critically short of time.

I will now quote a patient representative at an ICGP faculty consultation on regional diabetic care.

In all the care I’ve ever gotten for my diabetes, nobody ever asks me how I am! How am I feeling? It’s all about my HbA1C, the weight, the blood pressure, and the tablets.

The question of how someone is feeling is very important. We want time to address that with people.

Having sufficient numbers of GPs and practice nurses to switch on fully the practice of brief interventions in respect of mood, alcohol, better eating habits and stress handling is essential. General practitioners are highly and consistently accessible to families, parents, carers, children and adolescents. Turnover within general practice teams is exceedingly low, good continuity is evident in the provision of service over years and decades, and there is a high level of contextual knowledge in general practice teams which is simply absent in most instances in mental health teams and elsewhere within the health system.

What more can GP-led teams do? The ICGP is at present committed to delivering actively key national strategies, including Healthy Ireland, Making Every Contact Count, Sláintecare and Forwards Together. We believe we have good policies. We are collaborating actively with the National Office of Suicide Prevention, NOSP. In our elaboration of chronic disease management, we will be advising that mental health and end of life planning be reflected across all the main disease centres. It is not good enough to talk about diabetes and heart failure without looking at the attendant mental health issues that arise in these populations. In 2018, we will be rolling out another national programme of education for GPs and practice nurses on suicide prevention and deliberate self-harm, in collaboration with NOSP. However, we urgently need more GPs and practice nurses so that there is time for more, and earlier, talk therapy.

It is a most pressing concern that increasing numbers of rural practices and practices in deprived communities are closing. Elsewhere, the composition of practice teams is changing. They are very slowly getting bigger, accommodating the personal needs of younger GPs, who are more likely to work part time, and who will not work 60 or 70 hours per week as the current generation of older colleagues have done. In the context of these larger practice teams, the ICGP supports the idea of basing sessional allied health professionals, particularly in psychology, counselling and life skills coaching, in practices. We advise that the most appropriate skills mix be determined at the level of the practice with reference to the specific needs of the community. The ICGP is supportive of the role of more involvement by allied health professionals, but is impatient at delays in this roll-out and remains acutely concerned at the overall shortage of GPs and practice nurses.

In respect of GP-led teams and primary care teams, the ICGP is concerned about the experience of GPs with primary care teams, PCTs. We fundamentally agree with the advice that there needs to be greater networking in the middle and bottom parts of the pyramid. However, we have a lot of difficulty carrying out that networking. The people in the primary care teams do not have working email addresses. They do not have electronic medical records. They are not adequately connectable. We understand that there is a lot of activity in communities but it is not evenly distributed. Some of our colleagues are carrying out research on social prescribing and they are ensuring that their practices are more tightly networked to the services that are in communities. This all requires time on the part of general practitioners and practice nurses who have heaving waiting rooms.

We must look at primary care teams because so much has been put into them by the HSE during the past decade. Research conducted by the ICGP indicates that while over 70% of GPs are well disposed towards this type of networking and towards primary care teams, fewer than 13% of GPs surveyed reported positively on their experiences for the reasons I have given. While all individuals working in GP-led teams engage in full electronic communication, as I have said, most members of HSE primary care teams do not have functioning email addresses and utilise paper-based records.

GP-led teams have, as far as funding constraints have allowed, developed services relevant to people who attend them, but this occurs on an unsystematic and uneven basis, especially due to manpower shortages. The reality regarding mental health care is that most psychiatric illness is cared for in the general practice setting. Further investment here will enable better and earlier prevention in the middle and bottom parts of the pyramid, with less expensive intervention. However, it needs to be recognised that in Ireland, GP-led primary care is relatively and dangerously under-resourced. We are not short of policy. We have implementation deficit disorder.