Will the personal nature of your GP's practice be diluted by the plans to expand primary health care? Many doctors fear it will, writes Dr Muris Houston
It is a Tuesday morning in the "Moyview", Ballina, Co Mayo, family practice of Dr Pat Durcan, Dr Sinead Armstrong and Dr Anne Jordan. The waiting room is filling up with the first of the day's appointments for the doctors and the practice nurse.
I am here to see how a modern general practice functions and to hear what Dr Durcan, the senior partner, feels about proposals to incorporate general practice into a broader primary care team.
Patients consistently express high levels of satisfaction with their general practitioner. People can usually see their family doctor and nurse on a same-day basis, something that is often no longer possible in other countries.
General practice provides a broad range of services given in an intimate setting by a small number of health professionals. It is doctor-led and when compared with the hospital system, it is a model of equity where private and public patients are treated the same.
The Ballina practice looks after 5,000 patients, 1,500 of whom have medical cards. There is a commitment to see people on the same day they request an appointment, and 15 minutes is the standard consultation time. The practice is continually open from 9 a.m. to 6 p.m. and is commited to providing good quality care in a consumer-friendly way.
As well as three doctors, there is a full-time nurse, a practice manager and two secretaries/receptionists. "Under one roof, we can offer a choice of service - because of the special interests of the doctors - as well as a choice of doctor, and a choice of gender," Dr Durcan says. The importance of gender was brought home to him the day before my visit when a four-year-old girl asked during a consultation "are you a boy doctor, can I see a girl doctor please?" Referring to the strengths of the present system, Durcan says that the doctors seek second opinions of each other on a daily basis. Before a patient is sent to hospital, a second opinion from within the practice is sought, so that the hospital referral rate is low.
A local district hospital provides X-ray facilities, including ultrasound testing, which can be readily accessed. Physiotherapy is also available, and it is possible to directly admit older patients who become unwell and require nursing care.
In order to meet the commitment that patients are looked after on a same-day basis, the doctors see an extra six to eight patients a day outside the appointment system. There are about a dozen telephone consultations per day, a facility which the practice is keen to encourage.
An on-call rota operates at night and weekends, which is shared with other practices in the area. Up to 30 patients will be seen by the duty doctor during a Saturday and Sunday.
The key role played by general practice within the health service was obvious from many of the consultations I observed. An 8-month-old baby with bronchiolitiswas given drugs via a nebulizer. After she settled down, her parents were given the breathing machine to bring home, with instructions on how to repeat the treatment.
A sprightly 80-year-old from an outlying village returned to the practice for follow up. She had been seen over the weekend when a nasty cut on her hand was stitched and she was back for review by both the doctor and practice nurse. A good example of the management of trauma entirely within general practice.
The Moyview practice runs a dedicated diabetes clinic and a specialist asthma nurse visits once a month. Aedine Durcan, the practice nurse, describes the workings of the diabetic clinic. Each patient is seen every three months, when their bloods are checked and arrangements made for eye-clinics, foot and nail care and dietetic advice. Anyone whose diabetes is not controlled is seen monthly in the practice.
The launch of the much-vaunted health strategy last November included the separate publication of a primary care strategy. Primary care became the new buzz word; the strategy proposes sweeping changes in the way we relate to family doctors in the State. Enthusiastically welcomed at first, Dr Durcan and other GPs now view the proposals with some scepticism. This is partly because of the lack of action on implementation and partly because on closer examination, the proposals are seen as a solution to the crisis in hospitals rather than as a true development of general practice and primary care.
Even though it is eight months since the strategy launch, it was not until last week that the first meeting of the steering group for the primary care strategy took place. According to Dr Richard Brennan, chairman of the Irish College of General Practitioners (ICGP), this delay and the fact that a smaller and less representative task group has been driving the process to date, means that "the Department of Health has not demonstrated a willingness to engage with GPs at a strategic planning level".
The new concept of primary care will see general practitioners forming a team with public health nurses, home helps, health care assistants, occupational therapists, physiotherapists and social workers, as well as a full range of administrative staff.
The team will in turn link in to wider networks of dentists, dieticians, psychologists, community pharmacists and others.
So, from the patient's point of view the service will change significantly. The close one-to-one relationship with a doctor will be much diluted and while other resources will be made available as part of the change, both accessibility and relationships will be different.
Dr Durcan is in favour of developing the present GP team but feels that other health professionals, whether in the proposed primary care teams or networks, should remain outside a core team.
Brennan agrees. "It is vital that we walk before we run and develop the GP team first. Patients themselves want personal relationships and not care by team - they like being looked after by a tightly-knit group of individuals who have a deep knowledge of their health ." He is also concerned that issues of confidentiality will arise in a broader-team arrangement. "It is very important that people understand the implications of team care versus personal service," he says of the primary care proposals.
What are Dr Durcan's priorities for the development of general practice and primary care? "I would like to see medical cards given to everyone because it is the one way to ensure equality of care. Common hospital waiting lists would also benefit equal access." He would like to see the general medical services contract with practices rather than doctors, as this would allow the development of infrastructure to be carried forward from one generation of GPs to the next. "And I would be in favour of extra payments for quality based on the audited care of patients with chronic disease," he says.
The ICGP position on medical card eligibility is that it should be extended but based on need.
"Extra medical cards need to be targeted at people in disadvantaged areas first," according to Richard Brennan, who disagrees with proposals to extend eligibility based on age group alone.
He says that family practice offers the best form of holistic care. "The essence of general practice is the ongoing personal relationship between the doctor and the patient, extending into community and cultural relationships. Our skill is how we use these relationships as a diagnostic and therapeutic tool."
The fact that there has been little comment on primary health care in contrast to the public outcry over hospital services suggests that patients are broadly satisfied with what they've got. And while the development and widening of services in the primary care strategy has to be in everyone's interests, a key challenge will be to achieve this without diluting the personal and continuing care which GPs successfully offer patients.