‘A Seamless Service: Myth or
Reality’
Dr. Declan Murphy.
General Practitioner.
Kilkenny.
1. Introduction.
The Health Strategy document ‘Primary Care: A New Direction’ is a visionary, ambitious and realisable framework for the development of Primary Care in Ireland over the next ten years. For the first time in government policy the central role that Primary Care should occupy in the Health Services is acknowledged, and a time framed action plan has been drawn up to deliver on that policy. The Department, the Minister and the government are to be congratulated on a well-constructed and presented plan for Primary Care.
Reading this document was for me rather like a déjà vu experience. In 1987 the ICGP (then an academic toddler of two years old!) produced a major policy document called ‘The Future Organisation of General Practice in Ireland’ (widely referred to then as ‘The Blue Book’). It proposed and recommended many of the same proposals contained in this document, such as primary care teams, combined care protocols, access to diagnostic services and many more. It is regrettable that it has taken so long for government to accept the primary care system that many of us have spent a professional lifetime aspiring to. After all, the proposed reforms are very similar to those implemented over the past thirty years in many other European countries. This country has invested very little in the infrastructure of primary care, either financially or organisationally. For many of us, the re-engineering of the Irish Health Services has been a long wait and cannot come too soon.
The reforms that are proposed are immensely important, not only for those who will work within the new structures, but more importantly for the entire population who will deserve and expect the best possible primary care service. It is crucial, at this exploratory stage, to examine the proposals in detail for any loose threads, or potential unravelling of the seams. If my comments appear unduly critical it is not because I do not want it to succeed; rather I want to ensure its success by highlighting any flaws in seams that may not stand the strain.
A sheet is a garment without seams; so is a blanket. But the new primary care will inevitably be more like a patchwork quilt. At the outset we must recognise that all those who will make up the Primary Care Teams and Networks are unique and different – in some cases very different - both professionally and culturally, or else we will not succeed in creating a near seamless service. We need to recognise the characteristics of our work that make us different, so that we can create relationships and structures that accept our differences yet allow us to work in unison, with a shared vision, common goals and mutual confidence; in other words, to work together as a team.
The proposed Primary Care Teams will be based on existing general practices. Many, possibly most of these practices have already evolved into relatively simple teams, with two or more GPs, secretarial staff and practice nurses. To this structure it is proposed to add a number of others both paramedical and non-medical - a public health nurse, a social worker, an occupational therapist, for example. One of the initial requirements for teams is to produce a needs assessment for the practice population, a function of population medicine and therefore in part a public health role. It would seem important to have an AMO or similar appointment as part of the team or network. The precise team membership will depend on the particular situation. What is certain is that most members will be coming from the very different environment of the public service, where both workload and remuneration are largely predetermined and circumscribed. By contrast, GPs and their staff work in an entrepreneurial environment, where workload and remuneration are largely driven by demand, and the demand generally requires a same day response. The process of marrying these differing parameters has the potential to create difficulties, as the priorities of one team member may be quite different from those of another. Team leadership could become a contentious issue. The general practitioner would probably be seen by most as the powerful member of the team, and therefore the obvious choice to lead it. Successful team leadership requires a variety of skills, such as vision, diplomacy and the ability to motivate. It has different facets – strategic goal setting (the ‘vision thing’), implementation to achieve predetermined specific objectives, and accountability. The cohesion of the team will be undermined from the start unless each member is confident that his or her own role is given appropriate recognition. It could be helpful to look at other models of team leadership, from sport or business, for example. A football team has a manager who devises strategy and deals with discipline, and a captain whose role is to ensure that the team succeeds. A business has a chairman to oversee the overall goal, a board of management to set specific objectives, and a chief executive to make it all happen.
Governance will be another potentially contentious issue. To whom will an individual team member be primarily responsible - to their own professional superior, or to the team leader? Where does the buck stop? Suspicions that certain team members are not pulling their weight could quickly become a malignant cancer within the team. Inequitable division of workload has been as big a cause of breakdown of medical partnerships as differences over money.
The numbers of individuals named as possible team members is ten, and a further seven in the Primary Care Networks, between each of whom there will be an individual professional relationship to a greater or lesser extent. One can see that there is going to be a huge number of seams - 289 at least! Each of these will have further links outside their group, such as to secondary care, public health or health board administrators. The challenge will be to ensure adequate, appropriate and efficient communications within teams and networks, while at the same time preventing information overload, and threats to confidentiality. It is not an insurmountable feat, but many GPs have a phobic fear of endless meetings achieving little, yet tying up numbers of front line health workers. Creative and efficient solutions must be found, whether through computerised common records, teleconferencing, or even that old fashioned killer application - the telephone! Much emphasis is placed on the value of IT systems, in particular computers and software. The difficulties of getting each member of the team and network to commit to computerised records is likely to be immense, and progress is likely to be at the pace of the laggard rather than the early adopter. Incentives to computerise could come in unlikely ways. My own practice of five doctors plus attached nurses and secretaries has been fully computerised for the past year, and one of the unexpected benefits is the simple but very effective messaging system between individuals on the network, which has enhanced communications, reduced interruptions and eliminated the risk of messages not being received. However, a computer is simply another communication channel, and paper records have functioned very well for many years. Absence of IT is not a barrier to the formation of teams and networks, and we must not allow it to unduly delay implementation of the strategy.
The strategy states that teams will be required to identify health and social needs, and ‘this will necessitate the inclusion of personal social services staff on the teams’. With respect, it does no such thing, and there does not appear to be any convincing argument to support this statement. While one can support the general principle of ‘the need for community based health and social services in Ireland’, it does not follow that they need to be located under the same roof. Furthermore I believe that to include these services in the same premises as the health care services could be disruptive, even destructive to the overall aims of the strategy. It is not unreasonable to suggest that if people find themselves in a medical or health centre on social services business, they will likely find reasons to maximise the value of the visit by including a visit to the nurse or doctor, for example. This would be helpful if the visit is appropriate and productive. It seems likely that much extra work of little value will be generated on the ‘while I’m here’ principle. The document will need to include stronger arguments to convince GPs that this is an appropriate and productive development.
8. The SWOTs.
Strengths.
Some of the strengths are obvious, since the infrastructure already exists in large measure. There are 2200 General Practitioners in active general practice, about half of them in groups of two or more. Many of the remainder work in informal or formal association. All of them work from premises of some sort, and over the past ten years there has been a very significant upgrading of GP premises in most areas. Some of these are state owned health centres, most are privately owned, and many have the capacity for expansion. The acceptance of the principle of public/private partnership as a way of providing premises for teams will allow these existing premises to become potential team premises. The nursing and other non-medical professional members of the Team are also in active practice, albeit in a different setting and without formal links to specific GP practices. They have the challenging prospect of direct attachment to teams, and of transplanting into teams all that is best from their previous roles. Communications are so poor and haphazard at present that the only possible route from here is up! Patient and client records exist, but are created and held by the professionals concerned. It is perfectly feasible to create a system of unified records, ideally computerised; but in practical terms it may be slow and laborious and it would be important not to allow a secondary issue to defer or jeopardise the implementation of this strategy.
Weaknesses.
Universal patient registration is a prerequisite for assessing health care needs and planning preventive care and other strategies. At present patients nominate their GP in many situations, including GMS registration, maternity care and infant immunisations. The patient’s right to choose is fully protected, and transfer to an alternative GP can be virtually immediate, if so wished. The strategy states that patients will be encouraged to register with a team or doctor, but that it will not be essential. Human nature is such that, given the choice, many patients will wish to keep their options open and will not register. This is a recipe for failure. Universal patient registration is official policy of the IMO and the ICGP. It is used in every system that aspires to comprehensive, efficient and cost-effective care. The strategy’s cop-out is very disappointing and one that all of the professional organisations should strongly oppose. After all, while patients and politicians equivocate, doctors and teams will be blamed for the resultant failures.
To date there has been an absence of a culture of meaningful teamwork among the principal players. As individuals they have evolved methods of working that are generally effective but not ideal. They have been answerable only to themselves and their immediate peers. Team membership brings with it accountability and responsibility to the whole team, and this is likely to be perceived as threatening by some. The absence to date of a satisfactory communications between the proposed team members is closely related to the absence of teamwork. The formation of teams and networks will create a framework within which each individual’s worth and contribution will be better understood and valued. How many GPs have met an occupational therapist as part of their day-to-day work? And vice versa?
Opportunities.
A variety of health care professionals work in independent fiefdoms, in relative isolation from each other. Perhaps the best place to begin to correct this is in our vocational training, and later in our continuous professional development. There are many opportunities for joint training between GP trainees and specialist nurses or social workers, for example. This would lead to a better understanding of each other’s role, an increase in mutual confidence and respect that in turn will enhance team membership in the future. There is much ground to be made up, and all of us in our hearts know that primary care can do better. What is needed is the appropriate framework. Now we have it.
Threats.
Or do we? This strategy was delayed from one launch date to another. The media are rife with accounts of the arguments behind closed doors between the Departments of Finance and Health and their respective ministers. The document was immediately perceived to be strong on aspiration, weak on specifics. It was strongly and rightly criticised for its failure to address the scandal of the low ratio of medical cards, which is utterly at odds with the strategy’s core principle of equity. There is an implicit assumption that General Practitioners will continue to subsidise the medical needs of the marginalized group of families and individuals who are on low earnings but are deemed high enough to have to pay for GP care. There is a widespread debate in political circles about the direction that public services should take: European style social democracy, or American free market capitalism? Berlin or Boston? In health services the decision already appears to have been made quietly but effectively. We have a two-tier hospital system facilitated by a socially-regressive voluntary insurance scheme. The deliberate rundown in medical card numbers from 40 to 31% is creating a large cohort of patients who cannot qualify for one or afford the other. Primary care could be moving involuntarily towards a two-tier system also, against our collective professional ethos. Nowhere in this document do I read any statement that gives me confidence that this scandal will be dealt with adequately.
Yet it is the Action Plan that causes me the greatest disquiet. Action number 1 states: ‘A National Primary Care Task Force will be established… target date January 2002.’ That body has lead responsibility for eight of the following twenty recommendations, and joint responsibility in a further seven. It is described as ‘driving the implementation of the strategy’. Two months later that body has not even come into existence. This is not just a question of being fussy about starting dates. It is playing loose with people’s morale and commitment, and those are qualities that are hard-won, easily lost and cannot be bought on any market. The failure to meet or even explain the non-appointment of this body sends a powerful message to all those who care about the success of this strategy. Somewhere in the corridors of power there appears to be a lack of commitment to the strategy. Be assured that the goodwill and enthusiasm of the proposed team members will follow quickly in a downward spiral of cynicism.
Emphasis on structures, appointments and infrastructure may divert attention from the other less tangible requirements for success. A major factor for successful implementation of the primary care strategy is that it be flexible, capable of being moulded and adapted as experience is developed. The theory and practice of complex systems (also known as non-linear systems) is increasingly being used internationally in health service reform, and the evolution of a new form of primary care will undoubtedly lead to many emergent properties that will not have been anticipated. This paradigm is in direct contrast to the linear or reductionist approach, the rigidity of which is the cause of a lot of our present problems. In complex systems, individuals, groups and societies evolve ways of coping and solving problems that are not necessarily rational or predictable, but are effective. Each team and network must have the latitude to evolve its own distinctive dynamics so long as the overall goals are shared. Flexibility also is allied to a willingness to change in the light of experience. The caring professions are a paradoxical mix of conservatism and radicalism. These developments will be a test of our ability to retain what is valuable but let go of that which is not; of changing cherished routines, habits and responsibilities where it is going to be of benefit. For example, GPs will share or delegate to practice nurses some of those functions that they have traditionally monopolised, such as routine contraceptive pill checks and care of many chronic diseases. Social workers and public health nurses have traditionally worked with groups based on geographical areas. This has many advantages for them, but denies patients choice, and therefore runs contrary to the first principle of this whole health strategy, that of people-centredness. Each group will find itself challenged, and the necessary changes must be promoted as constructive and enhancing Some may accept change more quickly than others. Individual team members must be able to choose, but no one member should be in a position to sabotage the team’s efforts to move ahead. Change is not necessarily progress, and process and outcomes must be reviewed, audited and modified as necessary.
The success of any new venture will depend on many factors, but human factors will be no less important than resources. The Action Plan states that 20-30 implementation teams will be formed within the next two years, and a further 40-60 teams within the following two years. These will be the path-finders and opinion-formers for later teams. Selection of these teams must look closely at their personal characteristics so that there can be a realistic expectation of success. Failure of an implementation team in a particular area could be disastrous for further team formation in that area. It is not clear how team membership will be determined. Clearly it would best be done by personal choice, with opportunities for transfer in the case of dissatisfaction or incompatibilities. It is not clear how team leadership will be determined, but a number of ways are possible. Leaders will need skilling and re-skilling and support structures at higher levels. While the proposed National Primary Care Taskforce will drive the national implementation, there will be a need for regional directors and only those functions that are of national or strategic significance should be centralised at Department level.
All aspects of this strategy must be proofed against the core principles of the overall health strategy: Equity, people-centredness, quality, accountability. Yet even before there is a team in place there is flagrant lack of equity. One third of the patients entering the team premises will have full eligibility for all the services. The rest will have to pay their doctor and presumably the practice nurse. The policy of self-referral to any member of the team is understandable in the context of a people-centred service. How it will work in practice will be a key issue. Heretofore the general practitioner has acted as gatekeeper to some of these services, but self-referral is a logical extension of much of the development within general practice in more recent years. Quality assurance will be supervised by a number of bodies named in Action Plan recommendation 17, but surprisingly it does not include the Irish College of General Practitioners. The ICGP is an academic organisation, whose stated goal is to foster the highest possible standards of care in general practice. It is not a representative organisation, does not negotiate on pay and conditions, and is not directly comparable to the Irish Nurses Organisation, for example. It has a proven track record in innovative continuing medical education, has experience of quality assurance initiatives and has been a member of the EU organisation for QA in general practice, EQUIP, since its inception. Accountability is crucial, since so much of our present woes in the health service are directly related to lack of visible accountability. Action Plan recommendation number 17 on how and when accountability will be implemented or enforced is weak and unconvincing. Unless each team or network has an elected board of management, or suchlike, aspirations of accountability will remain just that.
I conclude by repeating my opening comments. For General Practitioners the Primary Care strategy represents probably the most important development in our professional lifetime. In order to make it virtually seamless, we must scrutinise every stitch and check every hem, so that it does not come apart when the strains are applied. If my comments appear critical it is because for me, and those of my generation, it has been a long time coming and there will be no second chance.
Finally I would like to commend the Irish Nurses Organisation on creating this opportunity to debate the Strategy in such a distinguished multi-disciplinary group. This has been a most stimulating and creative exercise for me, and I hope for all of us. In organising this conference the INO has done a major service for all of us who will make up the teams, and most importantly, for our patients.
Declan Murphy.
February 2002.