A new fragmented era for primary care

It’s the morning of Budget Day 2019 as I sit down to write this column. Well trailed in advance, the overall health budget is set to be €17.2 billion, an increase of 6.6 per cent, to include measures previously listed under the Sláintecare heading.

With health breasting the €17 billion tape for the first time, surely the draconian FEMPI measures will be reversed. And imagine the difference if the primary care budget became a steady 6.6 per cent of the annual health budget, rather than the measly 3.5 per cent it gets at present?

But you’re right, I need to snap out of my Walter Mitty-like reverie. General practice will be in as much trouble, faced with managing an additional 100,000 medical card patients on top of its existing stresses.

Those of us who were brought up on, and helped shape what was a reasonably successful general practice model in Ireland, have been hopeful of a return to stability and even growth in the sector. Sadly, and I take no joy in saying this, general practice as we have known it will never return to these shores.

This won’t come about for purely financial reasons: There are seismic societal changes already in train, which will be major drivers of this transformation.

Walk-in clinics, as already established in Canada and elsewhere, will be the choice of millennials and future generations. For the peripatetic young person, whose job location changes several times a year because of the contractual nature of work, having a relationship with a primary care physician is an anachronism. Not for them the hassle of making an appointment and driving to another city or county to the family doctor. Far easier to drop in to the nearest urgent care centre, be seen reasonably promptly, pay a fee and be on their way. Convenience, fast service, and price transparency matter much more than cradle-to-grave avuncular medical care.

In Ireland, we are clinging by our fingertips to the same-day medical appointment system. But it is crumbling, with practices here opening up a week’s appointments on a Monday morning when they are all snapped up within hours. For a younger generation used to convenience from most service industries, this is crazy. Waiting up to a week to have an acute problem dealt with makes no sense.

The trusted medical advisor (based on a long relationship), who coordinates their care, guides them to specialist services and helps them navigate complex treatment options, is not a priority in their world view.

What do this group value? Same-day appointments, hassle-free repeat prescriptions ordered via a dedicated app and sent straight to the pharmacy and a messaging system for the transmission of test results are minimal requirements.

They would like to be the true ‘owner’ of their medical record. Electronically portable, they would bring the record with them to urgent care clinics and specialist appointments.

I’m no fan of video consultations, but I can see the attraction for patients. Typically, eligible patients can register online in a few minutes and have a video consultation on their smartphone with a GP within two hours.

In Britain, <em>GP at Hand</em> is a free app that claims to offer most of the services of a traditional practice. Run under an NHS contract, <em>GP at Hand</em> is essentially a large practice of 20,000 patients that does most of its consulting online. Currently, to be eligible to register for the service, patients must live within 30 minutes of the physical location of the practice building in London. And while most consultations are carried out online, in some circumstances the patient will be required to be seen face-to-face.

The <em>GP at Hand</em> model answers one of my main concerns of video consultation and that is the complete lack of ‘hands-on’ involvement by the doctor. By restricting patient registration to those living or working within a half-hour of the practice centre, it is easier to turn an online consult into a person-to-person one when necessary.

But we don’t know how safe or effective such a model-of-practice will be. Indeed recent research shows that maintaining a relationship with the same doctor is associated with lower death rates in patients. Seeing the same GP has also been shown to decrease the number of specialist referrals made and make it more likely that the patient will follow medical advice.

It’s hard to see how any of the new models of primary care will not result in more fragmented care. It’s a recipe for over-treatment and also poses a significant risk to antimicrobial stewardship.

But at the end of the day consumer demand will win out. It doesn’t matter what we want or what best practice research recommends. General practice as practiced by many of us will fade away as society places a lower value on continuing care.

General practice in Ireland is dead. Long live general practice.