Is the emperor naked (are there really 222 primary care teams)?
Over eight years on from the launch of the primary care strategy, there are 222 teams in place. They are where 90-95% of health care needs can be met and Brendan Drumm’s pet project. So what do these teams actually do? Do they really exist? And how widespread are they?The primary care strategy as published in 2001 envisaged these primary care teams to be made up of GPs, nurses, home helps, physiotherapists, occupational therapists, some social workers, speech and language therapists and administrative personnel. Each team serves 8,000 people, is based on a model of team working that provides a better service for the patient and enables people to get their care in community. A wider primary care network with, pharmacists, dieticians, Community Welfare Officer (CWOs), dentists, chiropodists and psychologists was planned but has not materialised.
According to the HSE, there are 222 primary care teams (PCTs) up and running as of February 2010. The HSE’s definition of a PCT is that they have held one clinical team meeting. Teams hold regular meetings where all the team or representatives of the team get together and discuss a handful of the most complex cases and how their care can be provided. The regularity of the meetings varies btw weekly, fortnightly or monthly. Of the 222, 150 teams have met more than five times, 70 have met between one and five times and of these about 30 have had just one meeting – these are the more recently formed PCTs presumably. These multi disciplinary teams meeting are an indicator of whether the team is up and running and attended by all the relevant personnel – not an ideal measurement perhaps – but at least it is an indicator.
In 222 teams, there is huge variation in how often and how long such team working has been going on and how extensive it is. The HSE has set a target of 530 teams by 2011 and Brendan Drumm said in a memo to senior management just before Christmas that ‘by 2012, Ireland will have one of the best primary care infrastructures in the world’ – an ambitious statement by any reckoning…
So are the 222 teams an accurate reflection of what’s happening around the country or is it just spin?
If you use the HSE definition of just one clinical team meeting then true but if you think about it as how it was outlined in the strategy its not. However, even in some of these areas not all GPs are cooperating and whether you like it or not, GPs are central to an effective primary care service. Also is just one meeting a sufficient demonstration of a team?
So is Drumm’s illusive target of 530 teams achievable? Given that this plan is nine years old, that we have just 40% of the total number of teams operating, so for most of the country still does not have a primary care teams. While 530 by the ned of next year is ambitious, there is a renewed emphasis to get them all up and running in the HSE. No matter how much will there is within HSE management, this will be evener harder to do in the current environment of a shrinking work force, non replacement of staff and declining budget. Plus the unions are currently not cooperating with ‘change’ and won’t fill vacancies as part of their industrial actin since the pay cuts introduced in budget in December 2009.
Some of the teams are longer up and running in the originally envisaged HSE owned and built state of the art primary care centres. In these places there are very obvious benefits patients.
Previously, all the health professionals GPs, nursing, OT, physios worked in silos now they work together to the benefit of the patients. And while they may only discuss the most complex cases in official team meetings the fact that they are located in the same purpose built building and see each other day in day out, means they can provide a better, seamless service, in response to local needs.
Only about a dozen of these teams are in new state of the art primary care centres but many of the HSE staff are all working in the same health centres and the GPs down the road or near by. THe location of the teams is an area of contention – the HSE say it does not matter where you are located, it is the method of working that matters – whereas the Irish College of General Practitioners say that if you are not working from the same building then you are a ‘virtual’ team and that team working is not so effective.
GPs are self employed business people, while the rest of the teams are HSE staff, so there is no compulsion for the GPs to participate in primary care teams. And it does seem that there are different experiences in different places. As GPs are self employed they don’t have to work as part of a team or attend meetings. Some GPs say they cannot see any benefit of it. However, I think the majority who have experienced it, where it is working, while it may be a culture shock, they see quite quickly the benefit to patients.
In August 2008, the HSE carried out research on links btw GPs and PHNs in areas without PCTs. THey findings are extraordianry:
- 20% of GPs and PHN had never had face-to-face contact
- 56% of GPs and 77% of PHNs did not have each others mobile phone number
- 97% of GPs and 81% of PHNs had no working email address for each other
- Although 45% of GPs and PHNs were in weekly phone contact, as many 1 in 25 (4%) reported contact on less than an annual basis.
So if nothing else the primary care teams get the professionals working together and in doing so they provide a better service for the patients, keeping them at home and out of hospital with increased quality of life. Anyone can access them if you have a team in your area and by 2011, they are meant to be nationwide. And do you pay for them? Well, like most of our health system, the answer here is not clear cut and varies greatly from place to place. In some areas all services are free no matter whether you have a medical card or not, access is based on clinical need. In others you have to pay if you do not have a medical card but some services like public health nursing and home helps are universal – but provision varies greatly from area to area. And for me this is one of the biggest problems with health provision in Ireland, people just do not know who is entitled to what & its pot luck depending where you live.
There is currently a group reviewing this very issue – eligibility – in the Department of Health. HTe department has been reviewing eligibility for years now but apparently they will be making recommendations to government this year which will require detailed legislation (and this will probably take til next year to go through.) All this is taking place in the context of the Resource Allocation Working Group which is due to report to government by the end of April 2010.
In my opinion until there is clarity as to what you are entitled to and how you can get it, the public will remain sceptical. Also until people experience these enhanced primary care services, a credibility gap remains between what Brendan Drumm or Mary Harney is saying and what people experience on the ground in their day to day lives and their interaction with the health system.
Any thoughts on this or experiences of primary care teams are most welcome… I will contnue to monitor progress.