Address to the Association of Former Parliamentarians, Dr. Keith Swanwick, Seanad Éireann – 23 January 2015

Opening Remarks

On December 18th 2014, the Department of Health published – Health in Ireland: Key Trends in 2014.  It was an enlightening publication, full of many facts and figures about the underlying trends in our healthcare system.

For example:

  • In just over a decade life expectancy in Ireland has increased by almost three years and is now above the EU average.
  • In the same decade we have also seen an 18% improvement in mortality rates from all causes of illness and disease.
  • Finally, infant mortality rate is now 29% lower than it was in 2004.

To anyone reading this great news for Ireland (Brief Pause) However!!!! (Pause)

Three weeks later January 6th 2015 on RTE Morning Ireland, HSE Deputy National Director of Acute Hospitals was asked no less than eight times if this country’s major acute hospitals are safe places to be treated?  She declined all eight times to directly answer the question.

That same week one in every 12 patients was on a hospital waiting list and the nation’s ED delays had once again reached “national emergency”.

How is it possible to improve the health of a population – yet at the same time have the healthcare system itself that safeguards it, on life support!!!!

This is on top of a promise by the former Minister for Health himself a GP to never have an ED crisis again in this country?

Where are we going wrong?

INTRODUCTION

My name is Keith Swanwick – I am a GP and I run my own family practice out of Belmullet in County Mayo. I am also the Secretary of the National Association of Irish General Practitioners who represents 1,200 of this country’s GP’s. I am delighted to have the opportunity to speak to you here this morning. Over the next 20 minutes or so I want to talk about the realities of delivering healthcare in this country – and specifically primary healthcare in rural Ireland.

For decades, people have I am sure stood in this building, indeed in this very room, highlighting the woes of the Irish healthcare system and what major reforms are required in order to fix it.

So that will not be my starting point this morning. In the spirit of constructive debate, I’d like instead to focus on the opportunities that are there within our grasp. My message today is about the tangible steps that can be taken to enhance primary care services in the community and to allow primary care assume its rightful place within the Irish healthcare system as the first line of defence. It’s not about new spending – it’s about redirecting and rebalancing the current spread of resources towards the primary care setting.

Secondly – I want to touch on how a District Hospital – perhaps seen as a relic of a bygone era – should be seen as anything but, and in fact how such a facility with the right technology and personnel can still play an important  role in modern health service delivery in rural Ireland.

And finally to touch on an example of preventative medicine – in this case osteoporosis screening, in terms of patient benefit and how a comparatively small up front investment, can offset much greater costs down the line.

FUNDING PRIMARY CARE

My own professional experience is probably the best way of opening this discussion on why we should resource Primary care.

I moved to Belmullet in 2007 – the Erris area of North Mayo alone is the size of Co Louth. I saw a big deficiency in services being provided. My vision was to deliver a new and more alternative type of service in this remote location – an area which had a greater-than-average older population; poor road infrastructure and which is over 50 miles from the nearest major hospital – Mayo General in Castlebar.

In 2010, my wife and I opened a state-of-the-art medical facility in Belmullet, without any state assistance. We employ 9 people in total – 2 part time GP’s; 2 full time nurses one of whom is a midwife; a part time occupational health nurse; a practice manager and 2 front of house admin staff.

Our practice provides a range of services that are over and above what you would typically see in a remote GP practice.

These include:

  • DXA osteoporosis scanning
  • Antenatal services with an in-house midwife
  • Ultrasound
  • Cardiac investigations including holter monitor and 24 hour blood pressure monitors
  • Audiology
  • Spirometry for respiratory conditions such as Asthma, Chronic Obstructive Pulmonary Disorder (COPD).
  • Psychotherapy, Chiropody and Physiotherapy.

Our ethos is very focused on preventative community-based care for the patients we serve. Despite the current rhetoric about the need for more of this, in reality there is no encouragement for GP’s to provide these services in the community – with the result that many GPs typically refer people to hospital for these type of investigations which could be performed and delivered so easily, closer to home and outside the acute hospital setting.
Now – let’s consider the whole area of diagnosis, which establishes what is medically wrong with a patient. But it also helps to establish whether a person is sick or not. You may have heard the phrase from health experts about how to correct the health system: “Right Patient, Right Place, Right Time”. (PAUSE)

The right place for a patient seeking an initial medical diagnosis, is a GP’s surgery

Let us not forget that 80% of medical diagnoses are elicited from the patient’s own history and so I can’t emphasise enough the importance of having the time and ability to be able to listen to the patient, making sure they divulge what may seem like trivial information. A patient’s first encounter with the health system is so important. You can clearly see the advantages of having a strong and effective GP service as a first line of defence in establishing what the next step should be – in terms of hospital or home. Early diagnosis is also the mainstay of treatment – get in early and you have the widest array of treatment options available to you. Delaying the diagnosis will allow the opportunity for the disease to progress, which in turn limits the treatment options.
There are 2 costs attached to that scenario:
– firstly, the human cost in terms of the patient
– secondly, the cost to the system in terms of the costs of
dealing with a more serious and advanced form of the
illness or disease down the line.

People talk about a 2 tier health system in Ireland, but more recently I have been highlighting what I see as the 3 tier health system – where vulnerable patients with medical cards who are on waiting lists for diagnostics for an extraordinary length of time are forced to try to save funds to pay privately for their investigations, in order to progress their pathway to a final diagnosis. There are 27,000 patients in Ireland today awaiting MRI scans. These people can ill afford to pay and hence it is fundamentally unjust. Out of desperation, people often self refer to the hospital ED and once again it’s a case of the ‘wrong patient in the wrong place at the wrong time’.

What is required, is the redirection of funding back to primary care, to allow GP’s to regain their vital gate keeper role, and to let us do the diagnostics in the primary care setting – where it is more accessible – and where it’s infinitely more affordable – in most cases, the costs are as little as 10% of the cost of secondary care down the line.

GP practice is the cornerstone and future of this country’s healthcare service, and is the gate keeper to Secondary Care. If there is one thing I would like you to take from this discussion today, it’s this – the problems we see in secondary care will never be rectified until primary care, specifically General Practice, is adequately resourced.

What has happened in GP care over the past 7 years has been heart-breaking. With the institutions of state crumbling before our eyes, the one cocooned and protected space where doctor and patient could speak freely and openly in their own time, has also been severely compromised, and ironically at a time when it was most needed. Vulnerable people need a safety net particularly at a time when the entire country has been so badly hit by recession and economic austerity. The vulnerability of the patient should always be the rate limiting factor for treatment.

If we have learned anything from the most recent crisis in Emergency Departments nationwide – it’s that throwing money at the hospital sector is not the answer. I genuinely believe the cuts that GP funding has had to endure in recent years, have destabilised the fabric of medicine in this country:

  • We have seen a 40% funding cut to GP’s since 2010 totalling €160 million.
  • GP accounts for just 2.8% of Ireland’s health spend compared with 8.1 % of the UK’s.
  • Yet over 90% of all doctor-patient encounters occur in GP surgeries and these register a 95% satisfaction rating from the public
  • Most worryingly, 75% of all young GP trainees plan not to open their own practices here when finished training. Many of our brightest and best say they will opt instead for flexible locum work, and more again are opting to move abroad to better job offers in the UK, Canada and Qatar.

The fall out from this has been both inevitable and significant. Communities are suffering. 33 GP practices in Ireland in urban-deprived and rural areas are currently vacant.

So as we are faced with less people taking up GP practice here in Ireland – the great irony is that the Association of which I am Secretary, has been highlighting for some time a myriad of international evidence to show that GP-focussed initiatives such as direct imaging, access and admission processes, can  directly help to reduce the numbers attending emergency departments and other hospital services.

This fact was reiterated very recently by leading hospital consultant, Professor Garry Courtney, when he addressed the National Association of GPs in Limerick, and indeed he was echoing the views of the majority of hospital consultants in this country.

So there is a consensus across the system that General Practice must be part of the plan to resolve the ED situation and to do that, GPs naturally must be included in the creation of that plan. We are therefore disappointed and surprised that an independent voice for General Practice is not represented on the Emergency Department Taskforce. We believe that this is an omission that should be rectified.

MANAGING CHRONIC ILLNESS IN THE COMMUNITY

I want to talk for a few moments now about chronic illness and some initiatives which I think can help improve matters and to start here’s another insight from the “Health Facts” document I mentioned earlier.

At over 82%, Ireland has the highest score in Europe for its population reporting self evaluated ‘good health’ – that’s across 28 EU countries. I have no doubt that statistic is correct but despite this optimistic trend – Ireland, like all other developed countries, has a serious and indeed escalating problem with chronic disease. This is a consequence of a growing and ageing population, people living longer and  other societal influences such as obesity; alcohol etc. The types of illnesses we must deal with include:

Cardiovascular  – for example, hypertension, ischemic heart disease and stroke

Respiratory conditions such as COPD and Asthma

Diabetes

Rheumatological illnesses such as osteoarthritis and osteoporosis.

And of course Mental Health

The lion’s share of treatment for the management of chronic illness can be delivered in the community – where it is more accessible and cost-effective. And that is very much what we are about in Belmullet – not just out of necessity due to our ‘rurality’.

That’s a brand new phrase from a UK consultancy Lightfoot Solutions to explain why national ambulance response targets can’t be met – mind you, I could have told them that! We deliver these services in the community not because of our rurality – but because it’s the right thing to do for patients, and the health system benefits because it functions much more effectively as a result.

One very welcome new initiative  has been the setting up of  Medical Assessment Units – which effectively are triage and assessment units – adjacent to Hospital Emergency Departments. Used in conjunction with GP’s – these are can be a highly  effective buffer in keeping pressure off ED.

Much of what I am speaking about here today is about change – and change as you know tends to scare people. Over 100 years ago, the great American President Woodrow Wilson said “If you want to make enemies, try to change something”. When we look at the pace of technological change in the world today– it is a wonder that change is still such a challenge.

It is a great pity that despite all the challenges we face in society – we still meet great resistance in trying to change work practices; or changing policy stances; and changing attitudes even when this change is aimed at improving the treatment of others.

I am a pragmatist and I believe in making change happen – for the betterment of the patients in our community.  None of these ideas are ground breaking – but they are effective and easily achieved, and in the longer term will lead to better health outcomes for the public at large.

DISTRICT AND COMMUNITY HOSPITALS

The other great resource we could make more pragmatic use of, is our district hospital network, which is spread right across the country.

In more recent times, we have rightly seen the centralisation of key services – for example centres of excellence for cancer care in the main cities. However, not every aspect of the health service needs to go towards the centre, particularly if the service is to be truly national and provided to a population as widely dispersed as ours.

The country’s district hospital network is an example of a resource that is still very much in existence, which I believe l has an important role to play but which is seriously under utilised. There is one in almost every county – there are 4 in Mayo – so it is a nation wide resource, still functioning, albeit at varying levels. Because the network is there already – we are not proposing a new layer of bureaucracy. We simply need to make better use of the existing facilities.

The services a District Hospital can provide include:

  • Step down from secondary care, for example: post-operative recovery and rehabilitation;
  • As an interface with the Fair Deal system to alleviate the16 week delays currently being experienced
  • As an intermediate care setting to facilitate older people prior to integrating back into own their homes.

Of course the other benefit on offer is that early admission to a District Hospital can really help relatively minor medical situations from escalating into something more serious. For example – a medication review; or treatment of a chest infection, a chest x-ray or to allow patients access to other health professionals like chiropody/ physiotherapy – this type of early intervention and treatment can greatly assist in offsetting later admission into an acute hospital where the patient’s condition is invariably more serious.

There is a twin benefit in having a district hospital, in that you are both preventing admission to, and facilitating discharge from an acute hospital.

The role of the Medical Officer running these units also needs to be re-examined. It should be elevated from its current status as a comparatively low HSE grade to equate it to the grade of a Public Health Doctor. Add some modest investment into updating the facilities and you create an altogether new dynamic at a district hospital level around the country, that can allow this network assume new relevance in keeping the pressure off acute hospitals. It would be great to see the Minister announce a review of the existing networks – with a view to bolstering their status within the system.

OSTEOPOROSIS

I have spoken in broad terms here today about many initiatives – but I want to wrap up the discussion by talking about something that is very pertinent to this audience here today.

One of the highlights in our practice has been the roll out of an osteoporosis service for the community and a special DXA scanning machine to detect the early onset of this condition. Osteoporosis is what I call a silent disease – in that currently 300,000 people over the age of 50 in Ireland have the condition. It’s more common in women – in fact half of women in Ireland and 20% of men over the age of 50, suffer from the disease.

Osteoporosis has the word ‘porous’ in it, and it highlights the fact our human bone is a living tissue which, throughout our lives, is changing – it is being removed and replenished constantly.  As we get older, more bone is being lost than replaced,

In order to remain healthy, your bones requires:

  • Normal sex hormones,
  • Adequate dietary calcium
  • Vitamin D
  • Enough calories from your daily diet
  • And, most importantly as you get older, regular weight-bearing exercises.

Usually, people don’t know they have the condition until they sustain a fracture after a simple fall. This can be very debilitating and the pace of recovery from operations or injury is much slower.
The human cost of all this is that 50% of people over 60 who fracture their hip will be unable to dress, bathe or walk across a room unaided. Only 30% will regain independence. So clearly there is an urgent need for early diagnosis, better treatments and in more widespread locations.

As I said – diet is very important here because your bones are like banks – the more deposits you make, the more withdrawals you can count on. The symptoms are the sudden onset of severe back pain, the loss of height (up to 2 cm) and the patient can also develop curvature of the spine.

It is set to become a major healthcare burden in our society over the next 25 years. In the USA by 2025, annual direct costs from Osteoporosis are expected to reach over $25 billion. It is estimated that 90% of all hip fractures here are due to Osteoporosis. The cost to the Irish State due to osteoporotic hip fractures is estimated at €35 million every year.

There are multiple treatment options that will allow you live well and preventatively with this condition but the starting point is diagnosis and as explained before, the earlier the better. We are delivering this early warning service in Belmullet and I have no doubt that it will make a significant difference to the wellbeing of people with Osteoporosis in the region well into the future, and will allow them to live more healthily and independently into old age.

That is ultimately what our vision is for our practice – it’s something I am very passionate about and my own experience has shown me that for a comparatively small investment in these types of services in the community, we can transform how healthcare is delivered in Ireland and achieve greater health  outcomes for the communities we serve and help keep pressure off the secondary care system.

CONCLUSION

I have spoken at length about the need for positive change in how our health service is configured and geared – and truly this is not ground-breaking. It is clear that change is required and the first step is to admit that change is required. I do think that more recently Minister Leo Varadkar has acknowledged that GP’s are part of the solution and that the approach has to change.

In recent days he said:  “This time, if we’re going to get this right, we need to approach it differently.. and that involves, not more investment in hospitals and emergency departments, but more investment in primary care and social care.”

So I am hopeful that General Practice will regain the investment it has lost over the years and that this Minister, who many see as an enlightened individual, will bring to reality the commitment he is stating to community-based services as a strategic investment for the future.

Before I conclude – I would like to say to everybody here this morning that you are welcome to come to Mayo to see our practice first hand. The beautiful Barony of Erris – was voted by Irish Times readers last year as the best place in Ireland to ‘go wild’ – and if you make it up to North Mayo, in the spirit of the Late Late Show, I’d be delighted to offer a free DXA scan to everybody in the audience. Thank you