Shut solve health down hos­pi­tals to the cri­sis in

The Irish Mail on Sunday - - COMMENT - By DR PAUL GRUNDY PRI­MARY FOUND­ING CARE PRES­I­DENT COL­LAB­O­RA­TIVE OF PA­TIENT-CEN­TRED IN AMER­ICA

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.

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