Ireland the hope

Congratulations Ireland. I refer only to the Republic of Ireland. Long perceived as a deeply conservative country but a breath of fresh air is seemly sweeping through. Liberation of women’s and gender rights, a successful economy (many there ascribe this to being in the EU) and now a primary care centric radical healthcare reform. With such an emphasis on community-based services, it was a pleasure and privilege to give the keynote address at the Dublin conference ‘Integrated Care: Empowering People and Improving Experiences’ celebrating one year on of the Enhanced Community Care (ECC) programme.

What is the national policy that potentially makes Ireland the most primary care focused nation after Israel? And what led them to their insightful rationale for healthcare reform? Demographic trends in Ireland indicate that the population there is ageing even faster than any other EU nation and the UK. By 2028 there will be more people aged over 65 than under 14. This profound change will not be well served by the status quo. Health systems around the world have invested heavily in hospitals and specialist services to reduce the burden of disease from heart attacks, strokes, and cancers, but it is not enough. The imperative to address an aging population, the burden of chronic diseases (as they describe), and the lessons from recent global health crises have spurred Ireland to usher in a new era of healthcare, placing community care at its heart. Their rationale for the reform is inexorable which begs the question why not other countries as all have the self-same issues pending? And especially the UK with it
its well-established population-based GP system? Ireland’s GPs are private practitioners with no registered population.

So what is the substance of the reform that excites me? It’s the ‘reorienting of the health system’. These ambitious reforms go positively beyond the recent reforms in England. To wit, ‘’The Enhanced Community Care Programme’s objective is to deliver increased levels of healthcare with service delivery reoriented towards general practice, primary care, and community-based services. The focus is on implementing end-to-end care pathways that will care for people at home and over time, prevent referrals and admissions to acute hospitals where it is safe and appropriate to do so, enabling a “home first” approach. Fundamentally the ambition for this programme is to bring care closer to home. What is particularly commendable is the population focus.

The Sláintecare (Sláinte, Gaelic for health, pronounced ‘slawncha’) programme incorporates all the vision of the English Primary Care Home together with a positive supportive overall policy direction, an emphasis on the population responsibility of all care services and a focus on patient empowerment. A significant first for Ireland. But reform programmes however visionary, well thought out and ambitious can often be perceived as structural, top down imposed and disabling. I recommended an adaptive leadership by clinicians and managers alike to engender energy and indeed enjoyment and fulfilment- an essential radical shift from the traditional international healthcare managerial culture. Without that shift community-based clinicians will soon become disengaged, the very people who are of paramount importance for delivery. I fear similar for Primary Care Networks vis a vis ICBs and individual practices. I offered some of my oft articulated ideas, for instance the local Community Healthcare Networks (CHN), equivalent to Primary Care Networks, to aim to be a key anchor organisation for its community. (The CHN is the population base for GPs and in multiples, the population base for other community service and the hospital specialist services supporting chronic disease management). To further a new managerial culture, to own the concept of subsidiarity and two-way accountability and to paraphrase the late Philip Gould, “to see the patients as customers as well as citizens’. There is a pressing need to foster the importance of a relationships culture, not the frequent recourse to a top-down compliance-based culture. Community based services where care is more personal are particularly well placed for such a culture shift.

In the face of the unwelcome return of Covid-19, the need for resilient and agile healthcare systems has never been clearer. Once again, the elderly and the most vulnerable in society are in urgent need of attention and care. Ireland and indeed the UK stand at a crossroads in healthcare, grappling with often rapidly evolving scenarios and complex challenges. As we live longer, greater attention is being given to the needs of people with chronic conditions, in particular multi morbidity. These people need integrated care delivered by multidisciplinary teams with as much care as possible provided at home or close to home. Ireland has provided the clear policy leadership for this to happen, whither the NHS?

Postscript. The Israeli health care system is a universal statutory health insurance system. Every citizen is free to choose from among four competing, non-profit-making sickness funds, called health plans (HPs). Primary care is provided almost exclusively by salaried physicians (and other professionals) employed by the HPs, and independent physicians with whom the HPs contract. Primary care doctors play a gatekeeping role for access to secondary care. Most specialized ambulatory care is provided in community settings, despite recent hospital efforts to attract activity to their outpatient departments. In contrast, the hospitals are the main source of emergency care, with a relatively small but growing role for community-based providers (e.g. evening service centres sponsored by HPs and independent urgent care centres). Clalit is the largest of Israel ‘s four state-mandated health service plans. Their leaders reassured me that Palestinian and Israeli staff happily work side by side.