Are privately run state-of-the-art medical centres something to fear or welcome? Elaine Edwards reports
A medical centre to be opened in Mulhuddart, Dublin, by the Minister for Health next week will be the first of up to 60 such primary healthcare clinics which a private company hopes to build.
Its opening marks what the developer says is the future of primary care in Ireland, but the model has not been without controversy.
The Riverside medical centre, built at a cost of €6.8 million by the Touchstone group (a typical centre will cost between €10 and €12 million) will provide paramedic services and also retail units, built around a "core" of general practitioners.
The first big flush of primary care centres will open in 2007 - late 2007 at this stage. "This is a model, a shopfront for people to come and see," Touchstone managing director Fergus Hoban says.
The model, he believes, will fill "a great gaping hole" in primary care services and, he says, the Government has given its blessing to Touchstone's plan to offer incentives to GPs to set up practice in its centres.
Hoban says some 9,600 people in the Mulhuddart area were, until now, unserved by a GP. Already, the Riverside has its first patients and a number of GPs and dentists are working from its suites.
It is bright, well designed and very different from a typical GP's surgery, says Hoban.
Children sprawl on beanbags under a flatscreen TV in the waiting area. There are clustered seating areas with comfortable chairs or single seats at a breakfast bar-style arrangement facing out the window for those who prefer less interaction with other patients.
Hoban wishes to correct any impression in the media to date that Touchstone will directly employ GPs: while a minimum of six doctors will be required for such a centre, they will, he says, at all times be autonomous in their business and practice.
Ultimately, and if the regulatory environment allows, Touchstone wants to provide its own diagnostic and laboratory services on site, and potentially domiciliary care services.
Forty-four such projects, involving just over 250 GPs, are currently at development stage.
"We have an ambition to do 60 of these, which is about one-third of the potential for primary care centres in Ireland," Hoban says.
Potentially, a centre will provide services such as dentistry, physiotherapy, chiropractic, osteopathy, chiropody, podiatry, psychotherapy, speech and language therapy, and occupational therapy.
In Hoban's parlance, Touchstone is simply a "facilitator" for professionals to group together. It will provide property services (including site sourcing and contracting), and other advisory services, including financial and "change management" services.
GPs are offered a substantial discount on the market value of suites as an incentive to set up in a Touchstone centre, but Hoban says the company does not approach potential clients.
The fact that each centre will have a Touchstone pharmacy has not, understandably, been warmly welcomed by other pharmacists. And one prominent Irish Medical Organisation (IMO) GP said the model marked the "corporatisation" of primary healthcare.
Hoban says there will be no obligation on patients to use that pharmacy.
Dr Martin Daly, chairman of the IMO's GP committee, says he is not specifically directing any criticism at Touchstone's "very well developed business model". He says the IMO does not tell its 2,000-plus GP members how to "micro-manage" their practices.
But he suggests that rather than allow private companies to build such medical centres, the State should give GPs tax concessions to improve their premises and practices.
GPs, who have traditionally provided their own premises, find it difficult to invest in their premises and to improve them under "the current fee structure", Daly says.
"We feel the value of any such development should be to provide a modern premises and stream of income into the future to maintain the premises."
The value of GPs in any commercial enterprise should, he says, be maximised by continued investment in the practice from that enterprise.
Daly also says there must be clear safeguards and ethical guidelines to ensure the role of the prescriber and the dispenser of medication remain clearly defined and separate.
The primary concern of the Irish Pharmaceutical Union (IPU) is that, where Touchstone builds a centre on a greenfield site outside a town or village, that its own pharmacy will "literally corner the market" because of its location. This would, says IPU general secretary Seamus Feely, force out other pharmacists in the area.
"I think Touchstone would acknowledge privately that there are issues about the network of pharmacies and how they will survive into the future," he says. Feely makes the point that many people want to visit a pharmacy, even for advice, without ever needing to see a GP. "Patients will only lose out," he says.
In addition, the IPU says the presence of pharmacies in health centres "runs counter to the recommendations of the Government's own Pharmacy Review Group and its Primary Health Strategy".
"Are we seeking to increase the rate at which people buy primary care services?" Hoban asks. "Absolutely we are. Why? Because if people use a hell of a lot more primary care services in this country earlier in a disease state, we would not have one of the lowest longevities in Europe, one of the highest morbidity rates for a Caucasian population and untold misery in communities like this because of the absence of those services.
"Left alone, neither the State nor the existing delivery system can generate this kind of innovation and we feel that's our unique role."
On the surface, there does not seem to be a reason why anyone would object to the construction of state-of-the-art medical centres in up to 60 towns and villages, regardless of who funds them.
Although Hoban says no one who objects to the Touchstone model has been able to give him a precise reason why there is anything wrong with it, the underlying concern perhaps goes something like this: that the raison d'etre of such centres might ultimately be profitability rather than the health of the community and that their success or failure will come to be determined by that profitability.
Objectors claim the business model may mean, for patients - or "consumers" of healthcare, as Hoban calls them - less rather than more choice.
In the week that was in it, doing the sums was irresistible. The Riverside centre was built for €6.8 million. So, in very simple terms, the €150 million spent by the State on the failed PPARS system could have built 22 such clinics.