FUNDING: The ending of a pilot scheme that allowed GPs treat diabetic patients means longer waiting lists at hospitals. David Labanyi reports
Hundreds of diabetics in north Dublin will no longer receive adequate treatment because of a funding dispute, a hospital consultant has warned.
Dr Chris Thompson, consultant endocrinologist at Beaumont Hospital in Dublin, says that following the suspension of a diabetes shared-care (DiSC) scheme in north Dublin - which provided diabetes care at GP practices in conjunction with Beaumont diabetes clinic - the quality of care available to diabetics is going to drop.
More than 2,500 annual clinic visits provided under the DiSC scheme cannot be absorbed into the diabetes clinic at Beaumont, says Dr Thompson. The clinic has an 18-month waiting list for new patients.
The scheme collapsed in April following the failure of GPs and the Northern Area Health Board (NAHB) to agree a capitation fee for the service. As a result, more than 700 diabetes patients are now being referred to Beaumont for check-ups, but Dr Thompson says the hospital cannot cope.
DiSC started as a pilot scheme by north Dublin GPs in 1999 and enabled diabetics have their blood pressure, blood-sugar levels, diet and weight monitored in three visits a year to a clinic held by their local doctor. This was supplemented by one appointment with Beaumont diabetes clinic.
The benefit of such a scheme was that it reduced by 75 per cent the appointments at Beaumont's diabetes clinic, which was under severe pressure even while DiSC was operational. For patients, it removed the need to visit and queue in hospitals, and many diabetics using the scheme said they liked seeing the same doctor at every session.
GPs said the scheme also allowed the management of diabetes in the context of other medical conditions. This is particularly important when trying to motivate diabetics to change their lifestyle and behaviour.
The scheme ran on the basis that visits to a diabetes nurse in the GP surgery for blood tests were free. If the diabetic required a consultation with their GP, they paid a normal consultation fee.
However, GPs in the 29 north Dublin practices in the scheme are seeking additional payments for the extra workload, brought on in part by the growing popularity of the scheme. They also want funding for a dietician and chiropodist to work with the scheme.
The NAHB provides funding for a half-time specialist diabetes nurse who worked with the scheme. It said: "GPs are covered by nationally negotiated contracts under the General Medical Service Scheme and at the present time this contract does not provide for payments in respect of diabetes."
According to Dr Thompson, the problem facing Beaumont has been exacerbated by a sharp rise in the reporting of diabetes nationally in the five years since DiSC was established. It is estimated there are more than 120,000 diabetics in the State - and a similar number with the condition who have not been diagnosed.
"We can't absorb these people back. So they simply are not going to get the level of care they either had before the DiSC scheme was set up or that they have had since," says Dr Thompson. "The impact on these people is that they are going to have a worse level of care. There is no doubt about that."
Three people died last year on the waiting list from diabetes-related complications such as heart problems. "If the resources were available, these deaths could have been prevented," Dr Thompson says.
"The evidence shows that if you treat diabetes intensively it is not just a question of preventing the complications but, in fact you genuinely save money. This is not a pie-in-the-sky thing.
"There is economic analysis that shows that the prevention of complications saves money. By spending money to get cholesterol down and blood sugar down, you save money on dialysis and heart disease and by-passes and amputations - at the expensive end of diabetes," he says.
Dr Thompson denies he is frustrated with the stance being taken by the GPs. "We don't begrudge the GPs for pulling out of the scheme. The GPs started off this as a research study to prove it could be done in an Irish context.
"Three years ago we told the health board that if GPs were to continue to give up their practices and give up their time and to give up their staff, we would need to have an item for service payment for taking on a specialised clinic.
"The GPs have been doing this for altruistic reasons - and in the absence of a response I am not surprise they have pulled out. In Scotland or England, GPs are paid to do diabetes in primary care in the same way they would be paid to do cervical smears."
In response to the issue, the Eastern Regional Health Authority has made an application to the Department for diabetes-related funding, including shared-care schemes.
A Department spokesperson said it would be considered by the Chief Medical Officer and the general medical scheme (GMS) unit.
Malahide GP Dr Jim Kealy, the spokesman for the DiSC scheme, says the funding issues relating to DiSC are part of a general deterioration of primary-care services in the north of the city.
"The service was for patients normally attending Beaumont Hospital for four visits a year - that is the optimum care. The aim of the scheme is that you could give them as good, if not better, care in GP practices and take the pressure off the hospitals."
Other health board areas are also using the shared-care approach for managing diabetes. Schemes linked with St Vincent's and St James's are running in Dublin and there is one in the midlands and another in the north east.
At Irishtown Health Centre, Dr Tony O'Sullivan is involved in the East Coast Area Diabetes Scheme, linked to St Vincent's. He is also chairman of the Diabetes Federation of Ireland and a diabetic.
He thinks other schemes will fail within the next 12 months if there isn't a plan for funding. "The only element we are asking the Government to fund for the GPs is for the workload involved. We are not asking for payment for every scrap of care but we are saying 'you are paying hand-over-fist for hospital care', and patients should be allowed the choice of convenient care in the right location," he says.
He admits in his area the health board is contributing to diabetes care. It funds a full-time diabetes nurse and a full-time dietician to work with the shared-care practices and has paid for training days for GPs running diabetes clinics.
"For private patients it [shared care\] is expensive, for GMS patients it is time-consuming for the doctor. I just charge the standard consultation fee. I don't want to give them a financial disincentive to benefit from what I believe is a modern model of diabetes care."
Dr O'Sullivan says seven diabetics have joined his practice specifically to avail of the scheme.
Dr James Reilly, president of the Irish Medical Organisation, says he supports "entirely" the decision of the north Dublin GPs to suspend the scheme. He also strenuously denies that seeking a capitation fee for diabetes care is a "Trojan horse" for a fee-per item GMS contract.
"Our position is that shared care is an example of best practice and that the answer is to properly resource primary care. Secondly, it proves that primary care is the most appropriate place to carry out this sort of work. It also highlights the need for chronic illness schemes in the broader community, not just among medical card patients, like the Heartwatch Programme."
Dr Reilly argues that funding shared-care schemes makes economic sense because treating diabetes-related illness in hospital requires over 10 per cent of the overall health budget.