Presentation to the Joint Oireachtas Committee on Health and Children on Primary Medical Care in the Community
On behalf of the Health Information and Quality Authority, I thank the Joint Oireachtas Committee on Health and Children for giving me the opportunity to outline our submission in relation to the Joint Oireachtas Committee’s Report on Primary Medical Care in the Community. I am joined here today by Professor Jane Grimson, Director of the Health Information for the Authority and Marty Whelan, Head of Communications and Stakeholder Engagement.
Primary medical care in the community should play a fundamental part in ensuring that patients receive the right care, in the right place, at the right time. The Health Information and Quality Authority’s written submission focused on a number of key elements that contribute to the importance of good quality and patient-centred primary medical care in the community. For the purposes of today’s presentation, and within our allocated time, I will concentrate on a summary of these elements and will be happy to provide further detail on any element of our submission should the Members so wish.
Patient-centred Relationships and Information Sharing in the Primary Care Context
At the heart of effective, high quality, primary medical care is the ability of the primary care team to develop respectful and open relationships. These relationships are both within and between their team, with their patients and carers, other health and social care professionals, other stakeholders and the commissioners of their services.
These relationships are particularly important for patients who have long-term conditions and associated support needs (for example, diabetes, epilepsy and heart failure). These patients will require ongoing interaction with the primary care team, and, where appropriate, the majority of the management of their care should and could take place within the primary care setting. Currently, many of these patients are being treated within an acute hospital setting. Where such an admission or treatment is unnecessary, this adds additional time and stress for the patient, increases their potential exposure to healthcare associated infections, can result in increased bed occupancy and adds to the cost of the patient’s care.
Related to the issue of the provision and management of care in a primary care setting, is a concern both among General Practitioners (GPs) and their patients, over a perceived loss of privacy once patients become clients of a primary care team, rather than an individual GP. Where there is a need to share and discuss sensitive information about individuals’ needs in a team meeting setting, it is of utmost importance that patients are clear as to the purpose of such information sharing.
This is a particularly important consideration in small community settings where the individual being discussed is known to members of the team who have no direct involvement in their treatment. As a result, it is imperative that patients receive effective support that meets their needs from the primary care team and that any exchange of information and the purpose for such information sharing, is explained to, and discussed with patients in order for them to have trust in the confidentiality process of the system.
The development and implementation of an effective, public-friendly, robust information governance framework is essential. The Authority has a key role to play in this work, and is of the view that the Health Information Bill will be a key enabler for the legislative terrain associated with information governance.
Specialist Services and Workforce Planning
There are already good examples of where GPs, and the wider primary care team, provide specialist services for specific conditions within a primary care setting. However, there is an opportunity for this model to be expanded to better meet the needs of patients whose ongoing care could be better managed within the community.
Expanding the focus of more patient care management within the community relies on the necessary team-based support infrastructure to be in place. This includes access to the necessary medical, nursing, social and therapy support necessary to meet patient, and their carers, needs and safely support patients to appropriately remain in the community for their care. There will be an increasing demand for this infrastructure to enable more person-centred long term care, particularly as more of the population reaches old age, and the emphasis to keep people in their home rather than residential care increases.
Another desirable feature, which would enhance patient care within the community, is universal patient registration. This is a system where all individuals within the state are registered with an individual GP or primary care team. It would improve the quality and safety of care for the patient, health promotion, disease prevention, chronic disease management and more effective and efficient planning for the provision and resourcing of health services to better meet the needs of our population.
Additionally, the current shortage of GPs poses a threat to the ability of primary care to meet the increasing needs of their communities Therefore, there is a need for a Workforce Plan and Education, Training and Development Plan to be developed to meet the needs of modern day primary and community care for the next ten years which identifies and establishes the number of training places for GPs that are, and will be, required to ensure a higher quality and accessible service to patients and communities into the future. This needs to connect and support the implementation of policy such as The Primary Care Strategy, 2001.
To ensure patient-centred, appropriate and safe care for patients within the primary and community setting, it is necessary that GPs and the wider primary care team have direct access to the diagnostic tests and support services required to investigate and treat patients. To enable this, a much wider range of diagnostic investigations needs to be put in place at community level to reduce the need for patients having to attend hospital outpatient departments simply to get access to a diagnostic investigation.
It is also essential that there are effective communication arrangements in place for the ordering and result-receipts of diagnostic investigations between GPs and the respective diagnostic services. This includes, but is not limited to, radiological and laboratory-based investigations. There have been examples of where a breakdown in the ordering, receiving and reporting of tests between the GP and the diagnostic service, has resulted in adverse events for patients. This is not acceptable. There is therefore a requirement to ensure that the most effective and contemporaneous arrangements are in place for the communication of diagnostic investigations between GPs, the wider primary care team and the diagnostic service.
There are examples of where this already works well in Ireland, for example Healthlink. However, this is not uniform across the country and therefore there are varying degrees of safe and effective mechanisms to enable such an important step in the diagnosis and management of patients across the country.
Primary medical care should be the common point of oversight and accountability for the ongoing and periodic care that a patient receives whilst residing in the community. It is within the primary care setting where complications often manifest themselves and where the ‘window of opportunity’ for referral to specialist opinion is often instigated.
Therefore, it is essential that each primary care facility, including single handed practices, has effective and robust clinical governance arrangements in place in order to ensure the quality and safety of the care that they provide and also for the oversight of care that their patients receive during periodic episodes of treatment from different professionals and healthcare facilities.
Where a primary care practice is small, or there is a single-handed GP service, a number of practices can work together to support the time, knowledge, experience and resources required to establish such arrangements and the degree of objectivity required to manage them.
There are already excellent examples of clinical guidelines in the community including referral guidelines between GPs and acute hospital specialists. These guidelines form a guiding framework for clinicians working in the community. This supports the clinician in providing evidence-based practice and keeping up to date and also supports patients receiving equitable care across the country and being aware of the type and standard of care that they can expect to receive.
The continued development of these guidelines should be supported nationally, through an evidence-based and objective process, that enables ownership by clinicians and patients at all levels of the service, with managed plans for implementation. Such developments should be prioritised according to the key issues and risks for patients, for example, antibiotic prescribing.
Health Information and Health Information Technology
A key requirement for patient safety is the availability of accessible, accurate, robust and meaningful information that supports safe, appropriate, effective and timely care for patients.
Without this, the decision-making of a clinician may be ill-informed and inaccurate, and the safe transfer of a patient’s information will be compromised, particularly when care involves more than one healthcare team and more than one facility.
Comprehensive and accurate aggregated health information about the public, and about patients who access primary and community care, is fundamental in order for healthcare professionals, providers, managers, planners and policy-makers to effectively ensure that the provision of health and social care across Ireland meets the needs of the population at any given time. It also further enables the effective and prioritised planning of services for the future. Much of this information should be populated at primary and community care levels. This work is of central importance to inform the quality of care available, and to ensure that appropriate public health priorities are focused on, so that patients are more effectively treated, and so that people remain healthy both now and into the future.
At present, the collation, collection and monitoring of this critical health information is varied, sparse and, in relation to some areas, prevents informed decision-making regarding the provision of our health services. The need for robust information to drive quality and patient safety is well proven internationally.
In an Irish context, there is an urgent need to develop a fit-for-purpose Information Communication Technology (ICT) infrastructure in primary care that is interoperable with other healthcare services. A well-designed and implemented ICT system for primary care would:
- Yield valuable health demographic and morbidity information
- Enable better planning and targeting of primary healthcare services
- Lead to significant cost savings by avoiding service duplication, inefficiency and waste
- Improve quality and safety by, for example, reducing prescription errors
In addition there is a great to need to develop and implement a Unique Health Identifier (UHI) for every member of the population. This would be a key enabler for patient safety.
A core benefit of the use of UHI is that each individual’s health information can be safely and efficiently accessed and shared appropriately, through the healthcare system, and be tracked on an individual basis through each patient’s pathway of care. This will enable safer knowledge regarding the clinical history of the patient, including their previous care and any adverse events that may have occurred.
Recent public research undertaken by the Authority, which focused on people’s views on the use of their personal health information to improve patient safety and care, showed that 86% of people believe that their health information should be linked up across the health system. It was further found that the majority of people (96%) believe that the same number should be used to identify health information across healthcare settings, and in relation to privacy issues, 96% said they had the right to be informed of who has access to their information. This is a positive finding and indicates strong public support for the implementation of a Unique Health Identifier system towards the improvement of patient safety.
The seamless flow of information enabled by the use of Unique Health Identifiers is further supported by the implementation of an electronic health record (EHR). This will provide more accessible, accurate and patient-owned information to be available to primary and community care clinicians in order to most appropriately manage and treat patients, without the need for duplicating previous clinical history, which may also lead to inaccuracies and unsafe decision-making. The EHR should also enable clinical-decision support prompts that will support the clinician in ensuring that they are providing evidence-based practice.
Similarly, the EHR has the potential to more readily enable data and information to inform clinical audit to support the clinician and wider primary care team. The Authority strongly supports the development and implementation both of the UHI and EHR, and awaits progress of the Health Information Bill in this regard.
The arrangements for the provision of service by a GP, and or primary care facility, should involve a contractual arrangement that incorporates a clear expectation of the:
- service(s) to be provided
- clinical governance responsibilities and accountabilities of the individual and facility
- quality and safety, activity-based and demographic indicators to be measured and monitored.
It is important that such arrangements are clear and explicit in order to ensure that all services provided are robust, effective, well governed and the focus of the service(s) and care provided is quality and patient safety.
On behalf of the Authority, I thank the Committee again for this opportunity, and am happy to take any questions that you may have.
Marty Whelan, Head of Communications and Stakeholder Engagement
01 814 7481 / 086 2447 623