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ATAXI driver in Galway told me about his wife – the mother of his three teenage children – having a massive stroke at the age of 43. This devastated her life, and that of her family, and has cost hundreds of thousands of euros. All of it could have been avoided with better basic primary care (and simple inexpensive blood pressure medication) that would cost a few euros a month.
It was one of many conversations I had with people who have used the public healthcare system in Ireland during my visit from America to launch the European Association of Primary Care Partners.
This organisation will bring together medical staff of all stripes working in primary care across Europe, and allow for a single voice advocating for patients.
Lack of regular access to what we call a ‘primary care doctor’, and in Ireland is a GP, can leave families lost when faced with complex medical issues. When my own father died of complications due to congestive failure at age 87 he had multiple specialists but no personal primary care physician.
When faced with a problem which seems insurmountable, sometimes the answer is to do the opposite to what the received wisdom says. The conventional response to a crisis in health is to build more hospitals or open more beds.
But in other countries, that is not always the answer.
I understand from my interactions with Irish doctors and patients that you are facing into another winter of spiralling numbers of patients on trolleys. Thousands of patients will once again spend nights on trolleys waiting to be admitted to a bed.
MANY of them will be suffering from conditions or sideeffects of conditions which could have been treated before they became so ill. Many will have conditions that could have been treated by visits from a community intervention team but these are still not rolled out across Ireland.
I have worked closely with the Danish government on health, being named as a health ambassador for that country’s successful healthcare system.
With a 5.73million population and a land mass of 42,931km² Denmark is in many ways comparable to Ireland – population: 4.7million; land mass: 84,421km². I understand a hospital bed count is under way in Ireland at the moment, with the latest 2015 figures showing 10,473 acute beds in 50 public hospitals.
The OECD found an occupancy rate of 77.3% for hospital beds across Europe but in Ireland it is 93.8%. But in Denmark instead of opening new beds they have taken the opposite stance – they have closed hospitals, down from 120 to just 21 now. Every hospital manager has a mandate to close 35 beds annually with plans in train to merge existing hospitals.
I must stress this is not Denmark neglecting its hospitals, merely changing how patients access treatment. The Danish government plans to spend €6.4bn modernising existing hospitals and building specialist units. The money saved by this method in Denmark has been pumped into their community healthcare system, into primary care. Medics and allied health workers in the community benefit by having access to the diagnostics and treatment their patients need, and patients benefit by receiving timely treatment.
Now primary care accounts for 19% of the Danish healthcare budget, a stark contrast to the Irish figure of 3% on general practice. The UK allocates 11% to general practice.
Naturally, primary care cannot treat the most serious health problems which still need to be treated in the Emergency Department.
PRIMARY care doctors in Denmark are funded to take over the role of the hospital Emergency Department in some cases. In others the hospital and the GPs run an after-hour service with a clinic co-located in the hospitals.
Danish GPs can volunteer to take on more or less responsibility within this scheme and receive a higher rate of payment for after-hours than for normal care. Capitation does not apply to after-hours care. The first line of contact is a regional telephone service, with a GP deciding whether to refer the patient for a home visit or to an after-hours clinic.
In Ireland at present you will find GPs working in hospital EDs but they are doing locum work or filling in for someone; the Danish system encourages GPs to work as primary care doctors in the hospital setting with autonomy.
In America, I have been involved with a programme run in Maryland and Washington DC which has also shifted the focus to primary care under the CareFirst programme. The population affected here was just under 4million, so similar in size to Ireland. Patients in these regions have experienced 15% fewer hospital admissions, 13% fewer emergency room visits and 6.2% fewer days in the hospital recorded per 1,000 patients.
So how can Ireland introduce systems similar to those found in Denmark and in Maryland?
Ireland can work on preventative healthcare as a means to reducing waiting times and taking people out of the hospital system when possible by shifting the financial focus from boosting the acute hospital sector to bolstering the primary care sector.
This can be gradual change but it is firmly rooted in population health and depending on funding on a phased geographic basis. Your Sláintecare report should be seen as a journey to a destination. This is the approach that works best.
Looking to Denmark, they simply started off and built on the foundation of comprehensive integrated accessible and coordinated care.
The ‘Healthcare in Denmark’ report says: ‘The GP is responsible for ensuring that patients are offered the best possible and most appropriate treatment. The GPs are assisted by diagnostic and specialist support from the hospitals in the form of laboratory analyses, scans and X-rays.’
The majority of Danish patients have free GP access, and also free access to homenursing when referred by a doctor. The report also emphasises the merging of hospitals into large specialised units following the increase in patient treatments in the community sector.
FUNDING primary care to the right level has not always gone smoothly, with one major report noting it is difficult to control spending in primary care as it is based on activity. The authors say that as GPs treat 90% of patients themselves, reducing their funding would have a negative impact on hospitals so it must be carefully monitored.
Another challenge has been recruiting doctors to this sector with just 19% of Danish medics working as GPs and the EU average is 29%. Record-keeping has proved to be a challenge with reports finding it can be difficult to track care between the primary system and the hospitals. These ‘PatientCentred Medical Homes’ work on strengthening the links between patients and primary care doctors, even down to the level of making sure patients know the name of every doctor they come across – not always easy in a large setting.
This was something taken from the Danish model. When I spoke with Danish patients every one of them knew the names of each primary care doctor or nurse who had treated them. And this increases trust which in turn makes it more likely patients will open up about worries and concerns.
Dr Paul Grundy is a member of the Institute of Medicine USA and received the prestigious Barbara Starfield Primary Care Leadership Award in 2016. He is collaborating with Kevin McGowan, Adjunct Associate Professor of eHealth, TCD.