Primary Care - how far can it go?

Vorsprung

A lot of emphasis in the more informed health manifestos is on the expansion of primary care, in an effort to take pressure off the already stretched acute hospital sector.

I'd be interested in seeing exactly what people think can be reasonably expected, from a POV of diagnostics and treatment, as well as allied health care.

I've only worked in Ireland for one year but in that time I saw some good initiatives which made the relationship between hospital consultants and GPs more streamlined - one was the Neurolink which Tubridy set up in Vincent's, in association with an expansion in outpatient clinics - it brought the waiting list down from something like a year to a few months (more informed GPs might correct my on that, but it was something like that). Could there be a role for something similar involving other specialities?

I was reading about a new PCC that's planned for Killarney yesterday - looked impressive, and there was a mention of satellite clinics from consultants in Kerry/Cork happening in the future. Is this part of the way forward? I remember hearing about the Obs bosses in Dublin heading out to the likes of Navan for similar clinics, and it working well. Would is necessarily need to be a consultant that heads out to these clinics (let's imagine they're on every 2 weeks or every month) - could it be an SpR, and if there were issues that the SpR didn't feel comfortable with, just get the patient into the next clinic in the main hospital.

The other thing I was wondering about is whether the average is underutilised in terms of routine follow-up? Say you had someone with a AAA that's being monitored, and they're getting yearly or 6 monthly USS. Would GPs be happy to monitor this themselves, rather than being seen in the Vascular OPD, assuming that at the outset, the Vascular team had set out a clear plan in terms of regular imaging, and when they would need to see the patient again? Uncomplicated diabetes is another case in point.

Anyway, over to you.

And if you derail the thread I'm gonna get sam to ban your ass! :pac::D

MrCreosote

Good post vorsprung.

A lot of the chronic disease management could be passed onto Primary care, and probably will be. I reckon it would need some of the following, and wouldn't be hopeful that it will be set up. I think lots more responsibility will be foisted onto GPs without much of an increase in resources. What I'd like to see (in an ideal world):

1: Better access to lab testing and simple radiology. I talking plain radiology and USS, not PET scans and MRIs. If this can be offered outside the hospital all the better. A faster turnaround for bloods too.

2: Most important would be a complete overhaul of the communication between secondary and primary care. Discharge and clinic letters done on the day, electronically and with a clear and updated medication list including changes highlighted. These should only be done by the Reg or consultant. No handwritten scrawls arriving 6 months later!

3: Better access to outpatient geriatric services. This is the one area where I think the outreach clinics would work really well.

4: A ban on all drug reps. Bloody parasites.

drzhivago

MrCreosote wrote: »

Good post vorsprung.

A lot of the chronic disease management could be passed onto Primary care, and probably will be. I reckon it would need some of the following, and wouldn't be hopeful that it will be set up. I think lots more responsibility will be foisted onto GPs without much of an increase in resources. What I'd like to see (in an ideal world):

1: Better access to lab testing and simple radiology. I talking plain radiology and USS, not PET scans and MRIs. If this can be offered outside the hospital all the better. A faster turnaround for bloods too.

I disagree here completely to the thrust of the 1st sentence and this relates to man of the manifestos and before I get shot let me explain

By saying better access within the current system we are buying into the fact that radiology has to be in a hospital, why not have satellite radiology centres in cities and big towns, plenty of plain film radiology can be done, beamed through the world wide interweb pipes and reported within 24 hours far faster than waiting for routine hip shoulder/knee xray as the current standard is

Similarly for blood tests, why do we filter people to hospitals for blood tests, an outpatient laboratory regionally or in cities can do same, some GPs do routine phlebotomy and courier samples to labs (big costs for them in terms of time/access etc but they do it) I dot think they should have to the service could be more available.

when I was growing up we had a mobile library that came to village once per month, could same ot be done for phlebotomy, ultrasound etc, I mean we have mobile clinic for methadone!!!!!

MrCreosote wrote: »

2: Most important would be a complete overhaul of the communication between secondary and primary care. Discharge and clinic letters done on the day, electronically and with a clear and updated medication list including changes highlighted. These should only be done by the Reg or consultant. No handwritten scrawls arriving 6 months later!

Absolutely couldnt agree more and such an easy thing to do but talk to the techies and all they see is the dollar signs in overtime to implement a new system bigger than PPARS, this is not rocket science ad neither is IT

MrCreosote wrote: »

3: Better access to outpatient geriatric services. This is the one area where I think the outreach clinics would work really well.

4: A ban on all drug reps. Bloody parasites.

dont agree with the last comment, they are doing a job and a valuable one at that. If you dont want to see them tell them politely and they wont come but they have a role in the health service too

They can be very informative
will do some research on a related topic for you and bring you the evidence/papers/facts
for some of us they also are a refreshing beak from what is happening and can prove to b very enlightening if you take the time to listen to what they have to say

MrCreosote

drzhivago wrote: »

By saying better access within the current system we are buying into the fact that radiology has to be in a hospital, why not have satellite radiology centres in cities and big towns, plenty of plain film radiology can be done, beamed through the world wide interweb pipes and reported within 24 hours far faster than waiting for routine hip shoulder/knee xray as the current standard is

Similarly for blood tests, why do we filter people to hospitals for blood tests, an outpatient laboratory regionally or in cities can do same, some GPs do routine phlebotomy and courier samples to labs (big costs for them in terms of time/access etc but they do it) I dot think they should have to the service could be more available.

That's kind of what I had in mind. Where I work at the moment (not Ireland!)we have phlebotomy on-site with turn around for common bloods of half a day. Community radiology services are all around and the only attachment to the hospital is that they get their funding from the same place.
They are privately owned but contracted to the local health board.
Just makes it so much easier being able to do a chest Xray, or investigate a minor injury on the day without having to send someone to Emergency.

resus

or you could invest in near patient testing and do away with the labs all together for anything other than the weird and wonderful !

dissed doc

Vorsprung wrote: »

A lot of emphasis in the more informed health manifestos is on the expansion of primary care, in an effort to take pressure off the already stretched acute hospital sector.

I'd be interested in seeing exactly what people think can be reasonably expected, from a POV of diagnostics and treatment, as well as allied health care.:pac::D

All the suggestions are reasonable but none will ever work until this changes:

*Free at point of entry*

My experience of the UK, is that GPs can handle a much increased amount of work, based on the relationship with mental health community services, compared to Ireland. The major difference I see is that people will be put off going to a GP for certain investigations and returning the next few days or weeks if they feel that it will cost them €50 a go, or €20 or maybe something else entirely. This doesn't happen in the UK as we can liaise with GPs directly, book appointments, and the patient doesn't need to feel "will x charge, or will y charge, ". It's third world stuff in Ireland by comparison that we have brown envelopes with cash - sans envelope - in Ireland to get primary care.

So, there will never be a cohesive healthcare system as primary care in Ireland can be profitable based on reissued prescriptions - you don't need to provide a more advanced service at primary level in Ireland, so it never develops.

Instead, you have money poured into expanding sexy A/E units that of course are awkward to get to, inconvenient for people and never cohesively linked up to community services like mental health.

Primary care & mental health accounts for 80%+ of healthcare needs - you don't need to be doing MRI scans, or other expensive procedures if you can't even handle basic letter communications about outpatient appointments consistently between services. Walk before running, etc., .

drzhivago

resus wrote: »

or you could invest in near patient testing and do away with the labs all together for anything other than the weird and wonderful !

The BIG BUT comes screaming at me here

Near Patient testing NPT works well in volume scenarios where unit cost per test comes dramatically down and various forms of NPT can be done

If small volume then need to look at what tests give more bang for buck and weigh up costs, there is a role, i am not knocking the idea, we used in some of the DEs I worked in BUT cost is a major factor in GP land and cant see a single or small group practice taking it on when there is no reward and just a significant costs that patients would not really want foisted on to them

drzhivago

dissed doc wrote: »

All the suggestions are reasonable but none will ever work until this changes:

*Free at point of entry*

My experience of the UK, is that GPs can handle a much increased amount of work, based on the relationship with mental health community services, compared to Ireland. The major difference I see is that people will be put off going to a GP for certain investigations and returning the next few days or weeks if they feel that it will cost them €50 a go, or €20 or maybe something else entirely. This doesn't happen in the UK as we can liaise with GPs directly, book appointments, and the patient doesn't need to feel "will x charge, or will y charge, ". It's third world stuff in Ireland by comparison that we have brown envelopes with cash - sans envelope - in Ireland to get primary care.

So, there will never be a cohesive healthcare system as primary care in Ireland can be profitable based on reissued prescriptions - you don't need to provide a more advanced service at primary level in Ireland, so it never develops.

Instead, you have money poured into expanding sexy A/E units that of course are awkward to get to, inconvenient for people and never cohesively linked up to community services like mental health.

Primary care & mental health accounts for 80%+ of healthcare needs - you don't need to be doing MRI scans, or other expensive procedures if you can't even handle basic letter communications about outpatient appointments consistently between services. Walk before running, etc., .

Agree with most of what you say here but technicality in my opinion is that money not really pouring into EDs really, pouring into hospital sector but not EDs

Have worked in many which if Health and Safety or Fire Officers were allowed to inspect would be closed down, patients everywhere, beds trollies chairs and even lying on floor, cables trailing everywhere

Take CUH, one of the newer models, 60,000 or so come through its doors, the day it opened it was obviously too small and has 30+ patients on trolleys everyday

I worked in Oz, US and UK. In US a similar ED would have 80 Bays in ED and they would have proper beds, never a suggestion someone to be admitted to a plastic chair

Its money where mouth is time now with election, both fine Gael and Labour are looking at free primary health care which I believe in as long as resourced

The danger is expanding too fast when capacity not there and public feeling let down and rebelling against the concept. If it happens there will be an explosion in activity in primary care and some knock on to secondary care as people diagnosed with conditions because of presentations who would have ignored if it wasnt free