October 2002

There is serious dissatisfaction in the Republic with our health services in 2002. When I entered G.P. in 1970, first in the U.K., then in Ireland, it seemed that primary care was very much the poor relative to the hospital service but the hospital service was working well.

In Kilkenny where I settled in 1972 there were no waiting lists of major proportions, no beds in corridors, no overwhelmed A&E Depts. The major question was ‘choice of doctor’ in primary care and the politicians gave patients this in the new Regional Health Boards set up, which officially started in rural Ireland in January 1972. This replaced the old dispensary system, which had been in operation since the 1830’s. As a model this latter system had served the people very well but with the development of hi-tech medicine everything was set to change. For example obstetrics transferred since the early 1950’s from a home delivery system mostly to a hospital based system. Expectations increased dramatically among patients who had inculcated internally the notion that tests and hospitals were the sure answer to all medical problems.

G.P.s became the gatekeepers of the hospital service and carried on a busy but rather mundane existence of managing respiratory epidemics, childhood diseases and geriatric medicine with the odd emergency thrown in. Now it is the hospitals who are in trouble and unable to cope with demand and expectations. Primary care with its gradual improvements has remained much the same within the community albeit with a little more partnerships and technology. It responds almost all events with a same day response and in the whole health service has the highest rate of client satisfaction. However, our patients in our two tier system of public and private, are experiencing serious problems now with the hospital services. If you have V.H.I. cover you are very well looked after. If you are a public patient you might as well be in a ‘third world’ country. This is the analogy used by Dr Mark Harold, a psychologist in St Michaels House Dublin who is one of eight people putting themselves foreword as candidates in the upcoming general election in the so called ‘Independents Health Alliance’.

How is this appellation applied to general practice/ primary care and if it is so bad what new model can be put in place to give us a ‘first world’ health service. It is painfully and shamefully obvious when one travels in Europe viewing the health services there that people are genuinely puzzled by the fact of long waiting lists for everything. Citizens do not complain about health services in Europe – they complain about other things, mainly tax. Therein lies the clue to part of the problem – finance i.e. tax; the model of healthcare in Europe is very much more advanced. Hospitals are very much more advanced. Hospitals are very consultant led in all depts at all levels.

Primary care is highly organised with teams of medics and ancillary therapists working closely together. Technology has moved in large part back into primary care with all types of scanning routine and many therapies accessible to primary care delivery. In Ireland this was not happened (on both counts!) European countries spend nearly 30% of their health budget on primary care; we spend 10% approx. In a country such as New Zealand these changes have occurred well over a decade ago. We are frequently compared with New Zealand. Our healthcare delivery system is much inferior to New Zealand’s at least from the patients point of view. So what model? In the National Health strategy document ‘Primary Care – a new direction’, it is obvious to any level of inspection and perusal that the problems as outlined here above are acknowledged totally without pointing the finger at anyone or organisation in the past.

So far so good. When it addresses a new model and the implementation plan for same it borrows heavily from experience in Europe and other countries envisioning 20 – 30 primary care teams for implementation projects by a target date of end 2003 increasing to 400 – 600 teams in pace by end 2011. So far so good – in theory.

Remember not one such team yet exists in this country, this is a general election year, and the first target date of January 2002 for the establishment of the task force on primary care has come and gone and no sign of it yet… not good. A bad start. With all the administration in health nowadays it seems easy to produce documents such as strategies and drafts and very hard to produce working models: – caveat emptor. Will we buy into this? AGerman friend of mine, long resident in this country, offered the view in conversation that the big difference in the Irish and German health services noted by him (and he works in our service) is the vast amount of bureaucracy here. The problem in Germany is rather to limit the proliferation of working models in every health sector and keep costs down. The client/patient in this situation is actually spoiled for choice. But we must beware of pessimism lest we fail in our duty as doctors to provide for the well-being of our patients. Perhaps it is possible that Ireland will emerge as a world-class primary health care system if we can persuade the powers that be.

1. That it is essential to push ahead quickly with these plans as we have a long way to catch up.

2. That health finance for the primary care sector must constitute a larger part of our annual Budget to pay for these ambitious plans. (European level is about 40%)

3. That a health system so complicated in its evolvement has to be radically altered in its administration if it is to cope with a new model.

4. That Irish attitudes to many things will have to change if we are going to produce and provide continuously 24 hour services in primary care.

5. That many different service contracts will be on offer to participants in the new primary care teams enabling professionals flexibility – a key to future success.

The greatest minister for Health this Republic has had, Dr Noel Browne, dramatically altered Health Care delivery in the early 1950s. He built many hospitals, new primary care residences and surgeries in every county in Ireland, eradicated the scourge of T.B. finally…and all in a short space of time.

I did not share his politics but I worked with him for a while and knew him quite well. How did he do it? He was a driven man totally committed to his mission who used unorthodox methods if necessary such as the raiding of Irish Hospital sweepstakes funds for finance and who was always prepared to take on vested interests in the cause of equity and fair play.

This led to his Governments downfall over the clash with the I.M.O. and the Church in the mother and child scheme.

He had a very strict morality in what doctors should be striving for, in the essential justice of things in our sphere. We all could learn a lot from him.

October 2002