Dr Tom O’ConnorCollege Lecturer Economics, Public Policy &

HealthcareCork Institute of Technology

Speaker ProfileGPs have to be ‘renaissance’ people! GPs have a wide area of coverage I am the same! I teach economics, public health, social policy I research and write on: public finances, taxation, industrial

policy; public health, social care, health policy/economics I am passionate about fairness: have done quite a bit of

media work in this regard.GPs have large contact hours I work in an IOT and teach 18 hrs per week (upt two since

Haddington Road)Like GPs, I teach practitioners in the area of social care.Member of Economists’ Network at TASC; Chair of SWAN

CorkBook plug! O’Connor, T ed (2013) Integrated Care for

Ireland: articles by: Cork GPs, Diarmuid Quinlan, Joe Moran; ICGP; IMO; Prof Des O’Neill; Ivan Perry; Steve Thomas; Eithne Fitzgerald: John Saunders and more.

OutlineThe Macroeconomic context of Public Health in

Ireland under Austerity- Govt going in the Wrong Direction

Centrality of the Primary Care and the GP, referencing the Secondary Health Care System- yet continuing neglect

DOH/HSE ‘new’ Policy on Health & Social Care-Integrated Care.

Government Policy at Odds with HSE Integrated Care Policy

Reality in the Real Health ‘Angola’Conclusions

AusterityFrom 2008-2014 inclusive: 31.5 billion in

public spending cutbacks and tax increases.In 2011, the most recent year for which full

figures are available, total health spending in Ireland (OECD), was 8.5% of GDP. Of the 29 countries surveyed, Ireland had the 21st highest level of health spending. In other words, we were eight from the bottom of the 29.

Budget 2014Budget 2014: 113 million ‘savings’/cutbacks

in medical cards. At least 150,000 cards. Runs contrary to the Population Health of DOH & HSE.

Cut in 25 million to over 70s medical cards, at least 20,000 medical cards

Minister has stated he doesn’t know how many medical cards will be lost!

Complete lack of evidence base regarding public health.

35,000 over 70s to go from full to doctor-only medical cards

Free GP Care Under 5sIf we combine the cuts of 117 million on medical cards

with the introduction of free GP services for under-fives, it is clear that the services for relatively poorer and sicker people is being used to fund a universal service that has no new fresh income stream of dedicated funding.

While, the roll out of free GP care for children under five years is to be welcomed, it is of little comfort in the context of the savage attack on poorer people’s medical cards. Further, the figure of 37 million is substantially inadequate; Census 2011 shows that there were 421,000 children in Ireland under the age of five. This means that GPs will receive a gross amount of 95 per child per annum

Getting it Wrong: TroikaThe EU Commission, as part of the Troika is

demanding savage health and social care cuts going forward. In the last fortnight, despite the draconian budget 2014 cuts announced, the EU Commission has called for a further ratchetting up of cuts in the health/social care budget. This is based on their perception that cutbacks can be made, given that Budget 2014 estimates health spending at 13.3 billion.

Stuckler & BasuStuckler, D & Basu, S (2013)- The Body

Economic: Why Austerity KillsVerifiable evidence of increase in mortality and

morbidity directly attributable to austerity.Greece, 2011-13 – increase of 200% in HIV due to

cutbacks in HIV Prevention BudgetsDramatic increase in suicide and depression in

Europe and North America“Our politicians need to take into account the

serious - and in some cases profound - health consequences of economic choices," [Dr Stuckler-RTE News April 29, 2013]

Health Spending Mythology“Starting from 2010, a sharp reduction in health

spending led to a decrease in the health spending share of GDP”(OECD 2013:1).

In 2011, the most recent year for which full figures are available, total health spending in Ireland (OECD), was 8.9% of GDP, below OECD average of 9.3%. Of the 29 countries surveyed, Ireland had the 23rd highest level of health spending of 35 countries. We were in the bottom 40% of countries in health spending.

Going in the Wrong DirectionThe decrease in health spending since 2010

(OECD) in fact should be rising, from a population health approach, which the DOH/HSE says it is strongly committed to: The population of the Irish state according to the most recent Census (2011), rose by 348,404 from 2006 to 2011 and by 312,000 from 2002 to 2006. In fact, Ireland still has a rapidly growing population. It rose by 1 million from 1996 to 2011.

Breaking the Primary Care Lynchpin“The cuts of 7.5% to GPs are indefensible

based on the population health evidence which now presents itself. In the wake of a massive decline in hospital beds, an inadequate number of hospital specialists and growing waiting lists, and a dramatic rise in mental illness and suicide, the GPs are holding the Irish health system together”

(Tom O’Connor- Irish Times Sept 2, 2013)

Capitation Payments: circular HSE 009/2013GMS PCRS 2013 Post-FEMPI Males

€

Under 5 years 74.595-16 Years 43.2916-45 Years 55.2645-65 Years 110.3865-70 Years 116.28Over 70 in Community 271.62Over 70 in Nursing Home 434.15Medical Card Holders 5.3 visits pa. Non-Medical Card Holders 2.2 visits pa (ESRI 2005)

Critical Importance of GPIreland has 141 specialist medical practitioners

per 100,000 of the population, the second lowest of 26 countries (mainly EU) surveyed by Eurostat. Only Turkey is lower with 121 per 100,000. Germany has 216; Spain 240 and the UK 192.

The role of the GP is critical in all HSE plans prevent hospital admissions and move more to community care.

This is further evidenced by the fact that the GP is to keep people out of hospital in an a country characterised by a critical shortage in hospital beds (next slide)

Incentivised Payments: Asthma“These quality markers are derived from both the British

Thoracic society and the Scottish Inter-Collegiate Guidelines Network (SIGN) guidelines. The guidance explicitly states:

“It is important that resources in primary care are targeted to patients with greatest need - in this instance, patients who will benefit from asthma review rather than insistence that all patients with a diagnostic label of asthma are reviewed on a regular basis”.(6)

The success in the UK lies in sharp contrast to the documented outcomes in Ireland, as outlined above: almost 20,000 A&E attendances and nearly 5,000 hospital admissions, and 62 asthma deaths in 2011(4). The UK system rewards clinical excellence. The Irish system does not. The sole payment for asthma management under the GMS is a fee for nebulisation of a patient with asthma. This is a perverse disincentive to high quality structured care” (Quinlan & Moran 2013:154)

geo\time Hospital Beds per 100,000 1999 2003 2007 2009 2010EU (27 countries) 649.2 603.4 564.6 550.8 538.2

Belgium 781.4 750.8 663.1 650.8 644Czech Republic 773.6 772.2 730.6 711.4 701

Denmark 438.8 413.3 369.1 349.4 349.8Germany 919.4 874.4 823.9 823.9 824.8Ireland 624.5 567.2 514.6 327.4 313.9Spain 374.8 345 327.2 318.7 315.7

France 820.1 754.6 706 665.9 642.4

Italy 492.7 415.9 384.5 362.6 352.5

Hungary 824.9 783.5 718.6 714.4 718.2

Netherlands 504 450 474.2 465.7 :

Austria 808.2 773.3 774.7 765.9 762.9

Portugal 376.2 358.8 341.4 335.2 334.7

Slovakia 795.3 723.8 675.3 650.5 641.8

Finland 760.5 724.3 673 624.5 584.7

Sweden 369.8 305.1 286.4 275.9 272.6United Kingdom : 395.4 340.7 329.1 295.5

Hospital Beds: International Comparison“Ireland also has the 4th lowest number of

hospital beds per 100,000 of 28 Eurostat surveyed countries at 313.9, with an average of 538 beds across the 28. Germany has 825; France 642 and Portugal 347 (all figures for 2010 the most recent). As recently as 2004, Ireland had 564 hospital beds per 100,000”(O’Connor Irish Times 2-9-13)

Centrality of GPs in Primary Care Strong evidence in HSE policy that GPs are pivotal in

delivering integrated health and social care in the community.

This goes back to the Quality and Fairness Health Strategy/Primary Care (2001)

Centrality of GPs underlined in all DOH/HSE reports, particularly since the 2001 strategy.

Primary Care teams, GP at centre and Primary Care Teams (DOH 2001)

&HSE Integrated Services Model (HSE NSP 2011)Many others alsoDoH Health Strategy (2001) next slide

Primary Care TeamGeneral Practitioner 4.0

Health Care Assistant 3.0

Home Helps 3.0

Nurse/midwife 5.0

Occupational Therapist 0.5 – 1.0*

Physiotherapist 0.5 – 1.0*

Social Worker 0.5 – 1.0*

Receptionist / Clerical Officer 4.0

Administrator 1.0Source: Dept of Health (2001:24) Primary Care a New Direction: Quality and Fairness - A Health System for You Health Strategy

Note: new choice of professionals: podiatrists; OTs; SLTs etc

HSE (2006) Health Transformation PrioritiesPriority one: 'Develop integrated services across

all stages of the health journey'.Priority two: 'Configure primary, community and

continuing care services so that optimal and cost effective results'.

Priority four: 'Implement a model for the prevention and management of chronic illness'

Priority six: 'Ensure all staff engage in transforming health and social care in Ireland‘

This integration/transformation in HSE Integrated Services Model and National Programmes of Care (Mc Callion 2010; HSE NSP 2011, next 2 slides)

PatientPatientPatient

Home

Level IPrimary Care Teams

Level IICommunity Health & Social Care Networks

Level IIIIntegrated Service Areas

(Including Secondary Care Hospitals)

PatientPatient

7,00

0-10

,000

Home

Level IVTertiary Acute Services

30,0

00-5

0,00

0

100,

000-

350,

000

500,

000

+

National P

rogramm

es of Care

Nat

iona

l Pro

gram

mes

of C

are

Primary Care Care of the elderly Palliative Care Radiology

Obstetrics and Gynaecology

Obstetrics and Gynaecology (Deputy)

Joint Stroke

(Geriatrician)

Joint Stroke (Neurology)

Acute Coronary

Syndrome

Heart Failure Diabetes COPD

Asthma Mental Health Epilepsy Dermatology

Neurology out patients

Rheumatology Joint Acute Medicine

Joint Acute Medicine

Emergency Medicine

Critical Care Surgery

Unrealised Optimism“Mc Callion (HSE) pointed out in 2010 that 531 Primary Care Health Teams (now abbreviated to just PCTs) had been mapped out for the whole country to cater for these and other health care needs (level 1). Indeed, the following year, the HSE National Service Plan (2011c) confirmed that these had been formed and were in place. However, the Health and Social Care Networks (level 2) were still work in progress in 2010. Given that patients require a discharge plan before they can be safely left return home, as part of the new hospital configuration programme, hospital populations were to be synchronised to where integrated services were being rolled out. Integration was to happen by transferring ‘non complex acute services to local hospitals and/or PCTs'(Mc Callion 2010:11). These smaller local hospitals would work in close co-operation with PCTs and would have 'co terminous populations'. These non-complex hospitals are situated at level 3 of the integrated services model. The Primary Care Health Teams would be designated in to eight Integrated Service Areas (ISAs) nationwide but the PCTs (previously named PCHTs) would represent 'the building blocks for an integrated service area'(Mc Callion 2010: 12)(O’Connor 2013: 20/21)

HSE Model at Odds with Govt FundingTeams have common goals based on healthcare outcomes andshared values. They also have shared standards and operatingprocesses;• An average of five PCTs will make up a Health and Social CareNetwork (HSCN) serving a wider, but related, population of

30,000 to 50,000 people;• HSCNs will include a pool of specialised resources that serve

PCTcommunities;• PCTs and HSCNs will be integrated with hospitals, multi-

agencies,private providers, voluntary agencies, and with support groups (HSE, 2010a: 9).

Primary Care Centres ‘An investigation by The Irish Times journalist, Paul Cullen, based on

statements from the HSE and reports of meetings that took place in 2011

and 2012, reveals that, as of 2011, 297 PCCs needed to be sited andprovided to house 415 PCTs (Cullen, 2012). A smaller priority list of 200was put forward by Róisín Shortall in April 2012, based on extraweighting being given to areas of social deprivation. A final priority list

of30 was finalised later in 2012. The controversy between Ms. Shortall andMinister Reilly arose when she perceived that five extra centres wereadded by him in July of that year, of which she was unaware and wherethe correct criteria to justify their addition to the list was absent. This

listof 35 was released to the press. It included Balbriggan and Swords. Thepublic controversy that erupted resulted in the resignation of Ms.

Shortallmid allegations that Minister O’Reilly had pulled a ‘stroke’(O’Connor 2013: 33 )

Sample of PCC Progress CorkLocation No PCTs HSE RSP (2011) Status HSE South RSP

(2011)Update HSE RSP (2012) Update HSE RSP (2013)

Kinsale 2 Plans being prepared No update Work in progress

Ballineen 1 Negotiations underway Proposal subject to HSE Approval

Up and Running (not noted in HSE)

Cobh 1 New draft plan awaited Agreement for Lease signed Completion Q1 2014

Work in progress

Newmarket 1 Site location agreed-plans to be developed

Agreement for Lease Signed Q1 2014

Work in progress

Clonakillty 1 Potential site identified No update Work in progress

Fermoy 2 Negotiations ongoing Negotiations ongoing

Mayfield 1 Discussions ongoing Discussions ongoing Work in progress

Bishopstown 3 Location to be determined

No update No update

Glanmire 2 Progressing No update No update

Castlestownbere 1 Letter of Intent Issued: Negotiations ongiong

No update No update

Carrigaline 2-3 Going to HSE Board February 2011 for approval on rental details.

Proposal subject to HSE Approval

No update

Mahon 2 Lease agreement close to completion

Up and running Up and Running

Carrigtwohill 1 Layout plans finalising No update Operational 2013 (e)

Ballincollig 3 Layouts agreed: two sites No update No update

Unrealised HSCNs & Torturous PCC Progress “The reconfiguration objectives are those related to de-

institutionalisation, as confirmed by the subsequent report on Congregated Settings as discussed below. At the moment, there are supposed to be 134 Health and Social Care Networks (Irish Medical Times 2011) established to integrate with the primary care teams and further on to levels 3 and 4. However, apart from a change in nomenclature, there is little evidence of the actual existence of these HSCNs, presumably because most of the Primary Care Centres are not available to house the 531 Primary Care Teams that would integrate with these 134 Health and Social Care Networks. This would seem to be a significant challenge going forward.

(O’Connor 2013: 35)As of 2012- still a need for 297 Primary Care Centres to

house 415 Primary Care Teams (Cullen 2012)

Mental Health: Vision for Change

Primary Care Teams and Community Mental Health Teams (Vision for Change 2006)

Monitoring Group for Vision for Change Report (2011) ‘Mental health services had taken a “proportionally much greater reduction in staff numbers” than other areas of the health service, submissions to the body had said. The public service recruitment embargo made it “extremely difficult” to change mental health services as per the plan, the report said ....There were some 1,500 vacant posts in community health teams which were “poorly populated”, it said. There had been “very slow progress” in fully staffing community mental health teams, it found. (Irish Times 18-07-2012).

Drip-feeding of amounts: 20-35 million per annum still happening.

Budget 2014: 20 million is very inadequate, given scale of problem of mental health and suicide

Primary Care- Critical Importance

‘Other interventions such as Falls Clinics in the community for older people and enhanced geriatric community care, all liaising between primary care teams and health and social networks, are designed to keep people from being fully admitted to hospital or having to go in to nursing homes. In mental health Community Mental Health Teams are planned to liaise with Primary Care Teams to fulfil the gold standard of keeping mentally ill patients at home and utilising the same objective for the general population, the disabled and others with chronic or acute conditions, such as Diabetes, Asthma and other illnesses’ (O’Connor Irish Times Sept 2, 2013)

Disability & Older People-Lack of Health Promotion/Care also Impacts on Primary Care Integrated Services Model applies to disabled and older people in

particular, who need more health and social care support.

‘‘HSE Primary Care teams should be the first point of access for all medical and social care including public health nursing, home help services, meals on wheels, social work, psychological interventions, with a clear pathway to secondary specialist disability‐specific teams when required’(HSE 2011 – Time to Move on From Congregated Settings:9).

‘These support services have been ravaged by public expenditure cutbacks since 2008: for example cuts of up to 1 million home help hours have been introduced by the HSE in 2012 (Wall 2012); there has been an embargo on the public service recruitment which includes social workers. Even social work services in child protection have witnessed dramatic increases in caseloads to the point where they have ‘Big caseloads being juggled with little support’ (Irish Independent 21-6-12). These cuts are typical of those running across the infrastructure that is being planned for the delivery of integrated care, making it difficult to see how it the plans can be translated in to reality in the short-to medium term’

O Connor (2013: 36) The GP practice is the buffer when an old person falls, there is a COPD

episode, or asthma or other preventable health problems occur amongst disabled or older people.

CommentaryBlackrock Hall only PCC in Cork City- success

property developmentAre GPs expected to join consortia and become

‘team players’ and ‘property developers?In fact, anecdotal evidence that many GPs are in

serious financial difficultiesGPs have pulled out of PCTs in August 2013-

based on the impasse between reducing resources going to GPs and the increased workloads/policy plans on PCTs.

Also, Blackrock Hall charges those with medical card as private patients for multi-disciplinary services in physiotherapy and other associated health/social care interventions.

Reality BitesEx-Minster for Health Brian Cowen once described the Department

of Health as ‘Angola’The Primary care environment is becoming the real ‘Angola’. ‘As of Jul 1 2013, on the back of a 96% rise in hospital waiting lists,

the total number reached 48,279, with 3,062 waiting between nine and 12 months and 653 more than a year’(O’Connor Irish Examiner 7-11-2013)

‘More than 90% of all health care is delivered at the primary care level by GPs, nurses and associated health and social care practitioners. In 2011 we had 532,000 people over 65 years. In 2031, we will have more than one million. There will also be an increase of 370,000 people aged 45-64, according to Census 2011 Population Projections’. (ibid)

The care of older people is under enormous stress now, prior to the full effect of population ageing!

Hospital DischargeDischarge Planning:“It is important to recognise that discharge from a

hospital is a process, not an isolated event involving the development and implementation of a plan to facilitate the transfer of an individual from hospital to an alternative setting where appropriate. Components of the system (individual, family, carers, hospitals, primary care providers, community services and social services) must work together to ensure an integrated person centred approach and best outcome for the individual”

(Willie Reddy- HSE Programme Manager in Tom O’Connor Ed (2013) Integrated Care for Ireland.

Discharge to what?

CarersCarers Association consultation (2013):Cuts of a million home help hours in two yearsHome care packages are becoming almost non-

existentRationing of incontinence pads; reduction in

quality and sizeReduction in respite grant in last budgetDemands on GPs dramatically increasing (IMO

2011-13): older people with multi-system diseases; mentally ill; disabled; decline in public health since austerity in the economically developed world inc Ireland (Stuckler & Basu 2013)

Primary Care & GPs becoming the only ‘ports in the storm’Dramatic rise in suicide to 500 in 2012- an

increase to 30% of those with a mental illness, up from 25% in 2006.

‘It is virtually impossible to get Cognitive Behavioural Therapy on the public health system which tens of thousands need as the most proven intervention. GPs are again left trying to manage the situation and the various categories of patients including those with serious illnesses such as Bipolar and Schizophrenia, but also those who are addicted to alcohol and drugs’(O’Connor Irish Times Sept 2, 2013)

Conclusion

Health and Social Care are in a worse crisis than at any time in the past 40 years

Can GPs get the public on their side?GPs and the media- presenting the ‘truth’ .Incentivised payments a ‘double-edged sword’ under

current circumstances?The necessity for an Association such as NAGP is vital.GPs need to engage in political economy discourseThe Irish government is ignoring clear evidence of

severe damage to GP Practices and Public HealthMultiple ‘coalitions’ between service user groups,

other professions and GPs need to progressed in the battle for public health.