Topical Issue Debate – Primary Care Centre Provision

November 19th, 2013 - Pat Breen

Deputy Pat Breen: I welcome the opportunity to raise this matter and thank the Minister for Health for being present to answer my query. I acknowledge the progress he is making in reforming the health system, particularly when economic resources are scarce. Tweaking the existing health model as the previous Government did would never have delivered the fundamental change this programme of reform will deliver. I commend the Minister for his courage in reforming and restructuring the health system, building the children’s hospital, changing the way consultants work, reducing drug costs, improving waiting list and trolley waiting times, providing free general practitioner care for the under fives and, in time, introducing universal health care which will lead to an improved patient experience for all those who interact with the various medical services every day. That is important. If the health care system is to be transformed, we must eliminate the two-tier health system and provide a better service that will be more easily accessible. Primary care centres fulfil that role. They provide a broad range of services under one roof – a one-stop-shop for the provision of local medical services. These centres are the first point of contact for the patient and in the long run will provide considerable cost savings for the health system, given that they increase the lifespan of patients attending because they tackle small problems before they become big ones.
The Minister will be very much aware of the benefits of such centres having visited a facility in Ennis earlier this year. I am glad to report that planning permission has been granted for another centre in the vicinity of the town. However, these centres are being developed thanks to the efforts of GPs and private investment. The advantage of a HSE centre is that it provides equality of access for people across the board. We were all under the impression that Ennis would be included in the first round bundle of primary care centres to be developed and I was disappointed to hear yesterday that the HSE had not included it in its list of 16 projects to progress. Given the changes that have occurred in the hospital structure in County Clare in recent years, the development of a primary care centre in Ennis would alleviate pressure on resources at the Mid-Western Regional Hospital in Limerick. The HSE had indicated Ennis would be on the list of 16 projects to proceed.
I raise this issue on behalf of the people of County Clare. Are there obstacles to developing the centre at this stage? Is the HSE engaged in ongoing discussions with GPs to pursue the project as an operational lease arrangement rather than a public private partnership, PPP? Is this the reason for the delay? Will it be impossible to include a primary care centre in 2014? Has the development of private centres played a role in the decision? My office received a number of calls earlier from people expressing concern following a debate on Clare FM this morning. The Minister is committed to the health service and the delivery of health services for the people of County Clare. I would appreciate it if he could give an explanation to the House and provide the background, which might help to clear up the uncertainty that has arisen as a result of this announcement.

Deputy James Reilly: I am grateful to the Deputy for raising this issue. I am glad to tell the House that significant progress has been made in the development of primary care centres. A total of 34 centres have been built since the Government took office. On average, one primary care centre opens every month. Some 35 primary care centre sites were originally identified to be built by PPP, 16 of which have been identified as suitable. Many of the remaining primary care centres, including the one in Ennis, should progress and could be built by operational lease or inclusion in the capital plan.
The programme for Government sets out the Government’s commitment to ensuring a better and more efficient health system and a single tier health service that will deliver equal access to health care based on need, not income, which the Deputy mentioned. In a developed primary care system, up to 95% of people’s day-to-day health and social care needs can be met in the primary care setting. The key objective of the primary care strategy is to develop services in the community which will give people direct access to integrated multidisciplinary teams of GPs, nurses, physiotherapists, occupational therapists and other health care disciplines. This is central to the Government’s objective to deliver a high quality, integrated and cost effective health system. Modern, well equipped primary care infrastructure is central to the effective functioning of primary care teams. These teams enable multidisciplinary services to be delivered on a single site, provide a single point of access for users and encourage closer co-ordination between health providers. The infrastructure development, through a combination of public and private investment, will facilitate the delivery of multidisciplinary primary health care and represents a tangible refocusing of the health service to deliver care in the most appropriate and lowest cost setting.
The intention to date has been that, where appropriate, infrastructure is provided by the private sector through negotiated lease agreements. Where service needs dictate, accommodation will be provided in primary care centres for mental health service delivery. I had the pleasure of opening a centre with Deputies Catherine Byrne and Michael Conaghan in Inchicore last Friday. Not alone is a mental health facility provided for the community there, a 50-bed long-term care facility for older people is also being provided. New arrangements are being put in place to have specialists in older people’s medicine visit both the long-term unit and the primary care centre. This is part of our underlying plan and adheres to our principle of not only treating the patient at the lowest level of complexity that is safe, timely and efficient but also as near to home as possible. We must stop this idea of 50 people having to travel miles to see one person when a single specialist could travel to the centre and see the people there. That is what is happening in Mitchelstown, County Cork. Complete antenatal care is delivered in the primary care centre and patients do not have to travel to hospital in Cork to be seen unless they develop a major complication.

In 2012 the HSE embarked on a prioritisation exercise for primary care centres. However, the exercise is dynamic in nature and constantly evolving to take account of changing circumstances, including the feasibility of implementation. It is the Government’s intention to develop as many primary care centres as possible using one of the following methods: direct build by the HSE funded entirely by the taxpayer, or leasing arrangements with the private sector or PPPs. Considerable progress has been made in the delivery of primary care centres and 34 centres have opened since May 2011.

Ennis was one of the 35 potential locations for primary care centres to be developed by means of a PPP, but that has changed, as GPs were not in favour of that process. Ennis remains on the HSE’s schedule of primary care centres to be developed. An operational lease is being considered as the best option and it is the preferred choice of local GPs. The HSE continues to engage with potential developers who have expressed an interest with a view to making progress on this development as soon as possible. However, we will not build primary care centres that will lie idle, while GPs sit outside asking how much they will be paid to go in. That would not represent value for the taxpayer and it will not be allowed to happen.

Deputy Pat Breen: I thank the Minister for his reply and clearing up the uncertainty. I am delighted that he is committed to continuing the good work done, with 34 centres opened. Will he elaborate on the operational lease option? What is the timeframe involved? He said the HSE was continuing to engage with potential developers. I hope something will happen in 2014. The Minister’s commitment to the Ennis project should be commended. I will keep the pressure on him and the HSE to ensure the project goes ahead, given the changes to health services in County Clare in recent years.
Deputy Pat Breen: ] I raised the issue this evening so as to clear up that uncertainty. The Minister has provided some clarity and I hope the issue will be resolved in 2014.

Deputy James Reilly: We will continue to press for the development of a centre in Ennis, as well as at other locations. The critical point is to have the agreement of the general practitioners in the area to come to these centres. We are offering modern purpose-built premises where they can also interact with many other members of the primary care team. From my professional experience, if one has access to a physiotherapist, one sees the opportunities for one’s patients to be treated by that physiotherapist. However, if the physiotherapist is based many miles away, very often other modalities of treatment are brought into play or the patient has to be referred to a hospital to access physiotherapy services.
The same applies to mental health services. Many patients cannot afford to attend counsellors privately. If there were a public health counsellor in the primary care centre, a patient could use that service. What we would like to see in the future is a GP being able to refer patients directly to a counsellor without having to involve the psychiatric service because that is an inappropriate use of the psychiatric team’s time. The GP is well positioned to determine whether medication would be best delayed and counselling sought first. It has been well proved, both here and in other jurisdictions, that the latter modality of treatment has very good outcomes.
The potential for primary care centres and their use by GPs is enormous. Earlier I referred to Mitchelstown, County Cork. There is another large primary care centre in Mallow covering three separate practices. They refer to the fourth practice which allows them to deliver a range of services that no one practice could deliver on its own. With the volume of doctors and sub-specialisation among GPs, the centre is able to offer a much wider range of services to patients, obviating the necessity for patients to have to undertake long journeys into Cork city to avail of specialist care in hospitals there