JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 29 Jan 2009

Women’s Health Council.

Chairman

I welcome Ms Geraldine Luddy and Ms Alessandra Fantini to the meeting. Before we begin, I draw attention to the fact that members of this committee have absolute privilege but this same privilege does not apply to witnesses appearing before it. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

Following the presentation, members will put a series of questions to the witnesses. I thank them for the detailed document they supplied to the committee and for being present today to help us with our deliberations on primary health care. I ask the witnesses for a brief synopsis of their paper after which we will go to members for questions.

Ms Geraldine Luddy

I thank the Chairman and members for their invitation. We welcome this opportunity to participate in the committee's deliberations on medical care in the community. The Women's Health Council supports the primary care model of health service delivery. We believe greater investment in this model of care will bring improvements in the population's health in general and will do so with greater efficiency in cost.

The World Health Organisation's 2008 report on primary care shows that countries with a strong primary care sector have much better health outcomes at low cost and also that service delivery through primary care is cheaper than through the hospital system.

If we look at the model of primary care, we know that GPs are among the main health professionals working at this level and they are a key health service resource. The evidence we have from many of our own reports shows that GPs are the first port of call for women in regard to most health issues and, indeed, some social issues, such as violence against women.

However, the evidence also shows that there is a capacity and training issue for GPs. For example, in the area of mental health, women are likely to seek help and disclose mental health problems to their GPs but a study in the south west showed that 68% of GPs had no mental health training and 81% of GPs would like to have access to counsellors and psychologists, but they did not have that access.

Another example is the area of sexually transmitted diseases, or STIs. We know from research that 68% of GPs would like to have more access to further training in the area of sexually transmitted diseases but, at the time of the study, only 54% of GPs provided a STI service.

Some of these issues can be addressed with primary care centres. The advantages of these centres would be that additional services could be provided by other health professionals such as physiotherapists, psychologists, dieticians and practice nurses. The role of nurse practitioners could be developed through nurse prescribing in the community care setting. The more holistic and multidisciplinary approach would relieve pressure on GPs and allow them to expand services.

We also believe it would be important that the primary care centres would be in a position to link effectively with the hospital system because our research shows it is really important for the patient to have a continuity of care. We believe the centres could do this quite effectively with hospitals.

There are resource implications and we believe perhaps some funding could be moved from hospitals to care in the community. The shift in services should be implemented with attention to timing and public perception. For example, services in hospitals should not be closed down before community services are in place and able to cope with the demand.

There is also a need for an awareness campaign for the general public in regard to this shift in services because there is a perception that hospitals provide a particular kind of care which cannot be accessed at a primary care level and that people would not be able to pay for it at their GP. The perception is that they would get it free or more cheaply at a hospital.

That brings us to the issue of equity of access. Obviously, there is physical access to buildings, of which account must be taken. We also believe the current system works relatively well for disadvantaged groups and the very well-off. There is State insurance to an extent for medical card holders and those who are very well off can afford their visits to primary care centres and to their general practitioners, but a quarter of the population is uninsured and they do not go to their general practitioner because of cost. Among them are the poorer and sicker and they are the ones who suffer most. They do not attend until their illness becomes serious and by that stage they may need a referral to hospital so that the episode costs a great deal more in the long term.

We realise that financing is also a big issue. We looked at worldwide evidence which showed that universal coverage for primary care is best in terms of equity of access. Taxes and social insurance schemes provide a more equitable basis for health care financing whereas other types of private insurance and out-of-pocket expenses increase inequities.

I draw attention to the gender dimension and the need for gender mainstreaming, as per the national women's strategy commitments. Also, women are heavier users of primary care because of their biological and social roles. Obviously, men also need to be encouraged. We are pleased that the men's health policy launched yesterday takes this gender mainstreaming approach.

We hope the work of this committee will move along the matter of setting up the primary care centres. I thank the committee.

Deputy James Reilly

I thank both Ms Luddy and Ms Fantini for coming in today. Ms Luddy's contribution has been very useful. She clearly has a strong understanding of general practice and what it could deliver, and what primary care can deliver. I agree with everything Ms Luddy said on the use of the services by women, the poor use of it by men, and the issues surrounding those who are above the medical card income limit, which at half the minimum wage, is very low.

The medical card situation is akin to the position that has evolved in the United States where 50 million uninsured people face bankruptcy should they fall ill. Luckily, in this country there is the safety net of the hospital system, which is free to everybody but the access to which is a major issue. That is why we are holding these plenary sessions on the development of primary care. Primary care, if properly developed, could remove a considerable load off the hospital system, both in terms of reducing people going to hospital and in terms of getting people out of hospital earlier.

Ms Luddy mentioned the gender issue too. It is difficult to get a male general practitioner. In the younger age groups, it is very much the case that female doctors are coming through. That is one area, at least, in which women are achieving balance, and more than balance which may be problematic in the future. This has had implications in terms of the whole-time equivalents. It is not just because more women want to work part time. It is also because more men who are coming through now want to have a life outside of their careers. The old days of 24-7 general practitioner on-call single-handed practice is disappearing, and some would say properly so because it is not safe to be on call all night. It is one matter doing it when one is a junior, which is dangerous enough, but to do it in one's 50s and 60s on an ongoing basis takes its toll and cannot lead to best practice in my view.

Where could it improve? Specifically, what does the Women's Health Council want to see added? Ms Luddy mentioned the mental health area on which the committee received representations yesterday. Certainly, that is an area where even the HSE agrees it is suited to be carried out in primary care. Are there specific areas of women's health that can be improved, or how would Ms Luddy see primary care developing to improve that? For instance, an aspect of the new primary care centres that I would like to see built would be rooms for visiting consultants so that the specialists would travel to see people in the community rather than the converse — 35 people turning up at an outpatients' clinic at 9 o'clock — which is ridiculous.

Deputy Jan O’Sullivan

Ms Luddy's presentation and the document she gave the committee is useful in the context of what the committee is trying to achieve in terms of making recommendations.

At the beginning of her presentation Ms Luddy referred to the WHO research that would suggest better outcomes and lower costs where there is a strong primary care system. I looked at the references at the back of her presentation and could not find that one. If she could forward that reference it would be useful.

From the point of view of a Government, better public health outcomes are usually achieved over a long period. In the committee I have often referred to Finland where, in particular, they appear to be getting better outcomes, in terms of reduced obesity levels and other areas. Does Ms Luddy have anything further to say on policy making and in practical terms how a Government transfers funding to achieve better outcomes which probably do not have any great short-term result? That question is probably more appropriate for a Government member but it is important. Increasingly, it seems little emphasis is placed on spending on preventative medicine such as healthy lifestyles and there is constant pressure to spend on areas such as patients on trolleys. If Ms Luddy has anything to say on that I would be interested in hearing it.

Deputy Margaret Conlon

I thank Ms Luddy for her presentation. I welcome the delegation and thank it for the supporting documentation provided. I have two or three short questions.

Has the Women's Health Council been consulted at any stage by the HSE on the setting up of the primary care teams and how it could contribute to the effective development and delivery of services by primary care teams?

The other point Ms Luddy made which struck a chord with me is that services in hospitals should not be closed down until everything is working effectively. That is a view I share. The primary care teams are not a replacement for acute medical care and there will still be people who need to be hospitalised, but if one's primary care teams are working effectively and have been monitored, reviewed, tweaked and changed where necessary to ensure effective delivery, the services in a hospital will withdraw themselves without having to be closed down.

I would also see an important role for the primary care teams in women's health promotion and continuing to encourage patients. If women can go to a setting where there is a service like BreastCheck, smear tests or whatever, they are more likely to use it than if they must go to their general practitioner for a referral elsewhere. If that service is provided in the primary care setting, the chances are women will be more likely to use it. We spoke yesterday about the promotion of health lifestyle among men and the same can be said for women. The primary care teams can play an important role in health promotion and health education.

Deputy Rory O’Hanlon

I thank Ms Luddy for her presentation and also for the useful documentation. The committee is meeting a large number of relevant bodies with a view to trying to draw up a policy on primary care. Primary care has been fragmented over the years and the Government is anxious to have primary care teams in every community throughout the country for the future. While Government is working on that, this all-party committee is seeking to identify best practice and see what we can do to ensure best practice.

I am interested in Ms Luddy's input. In my view, women are much better patients then men. They are more objective about their health. They attend the doctor when they should do so and do not put off doing so to the same extent as men. Perhaps they have a great deal to teach men.

The area in which I am most interested is prevention. Our guests have a critical role to play in that regard, not only by ensuring that women attend for screening in respect of particular illnesses but also with regard to matters such as coronary artery disease, which is becoming more common among women. It appears that women do not always take the necessary precautions to try to prevent and reduce coronary artery disease.

I am interested to discover whether our guests have carried out research in respect of the labelling of food. All products in the food sector must carry labels listing the various ingredients, the number of calories they contain, the fat content, etc. However, this information is not presented in a user-friendly way and is not standardised. If one looks at similar products on a supermarket shelf, one will discover that the nutritional and food content and information relating to the ingredients are presented in different ways. It must be difficult for people reading the information on the side of a packet to assess the value of particular products in the context of the benefits they might provide, the low fat content they contain or whatever. Has any work been carried out in this regard?

Our guests referred to GPs, mental health and access to counsellors and to treatments for sexually transmitted diseases. Some GPs take a particular interest in this area and would be well equipped to deal with people's needs. There are those who are fortunate enough to live in communities in which there are extremely good liaison structures and where people have the opportunity to discuss and be well informed with regard to, for example, mental health services. I was extremely fortunate to practise medicine in the Cavan-Monaghan area. In 1966, community psychiatric nurses were already working in the district. The authorities in the area were very progressive in the context of pushing back the frontiers. Great opportunities existed in Cavan-Monaghan at the time.

I agree with the issues to which our guests referred. We must consider how, in the context of primary care services, we can ensure that those issues are dealt with in order that people might benefit.

Chairman

Would Ms Luddy or Ms Fantini prefer to answer those questions?

Ms Alessandra Fantini

Would the Chairman prefer if I replied to the questions in the order in which they were asked?

Chairman

That is entirely up to Ms Fantini.

Ms Alessandra Fantini

The reference to the 2008 report is contained at the bottom of page 7 of our submission. I can also provide members with a link to the relevant website.

In the context of what could be added and the areas where primary care teams could really bring about benefits in the area of women's health, we are of the view that major benefits could already result from the way they have been laid out. There could obviously be access to better mental health services, possibly through the availability of psychologists or counsellors. Chronic illness clinics could be transferred — not necessarily completely eliminated from hospitals, if that was required — to primary care settings. The introduction of nurse prescribers means that these individuals could play a leading role in running such clinics. This would alleviate the pressure on GPs as well as the hospitals.

As already stated, there is no reason GPs cannot deliver a greater level of STI services within their practices and primary care teams. For many reasons, however, they are reluctant to do so. Some of these reasons relate to their own training but others relate to the lengthy form-filling that is required and the need to have access to laboratories and to wait for results. These logistical issues could also be addressed. There might be efficiencies to be gained in primary care facilities that are servicing larger populations.

We referred earlier to the importance, in the context of prevention and healthy lifestyles, to including dieticians in primary care teams. This would mean that not only would we treat people who are already overweight or obese, we could also refer people whose lifestyle might cause them to overeat or not take adequate exercise.

There is a great deal that could be done. Many of the illnesses or health problems that will prove more costly or that will affect the vast majority of the population are linked to unhealthy lifestyles. For example, obesity can give rise to people contracting type 2 diabetes in many instances. Being in a position to consider lifestyle issues, provide advice in respect of people's diets and suggest how they might engage in physical exercise in a way they can afford — which is not always easy — is important. In addition, healthy food is extremely expensive and this is a matter to which consideration must be given in the context of prevention.

On specialists, developments in this regard could be welcomed as long as the equity of access issue remains paramount. It would not be desirable that there would be specialists whose services some people but not others could access. As long as these specialists were available to everyone using a primary care facility, there would be no problem.

Many women do not use the services of their GPs for their maternity care. Even when they are not in the high-risk category with regard to their pregnancies, they still attend at the hospital. Perhaps this is more for a sense of security. However, GPs can provide maternity care services and perhaps something should be done to increase public awareness in this regard. Many GPs do not, for whatever reason, sign up to the mother and infant care scheme. A large proportion of women are not aware that, while they are pregnant, they can attend their GP for free. Unless the GP raises the matter, many women are not aware of their rights in this regard. Again, this is another issue in respect of which public awareness might be raised.

Members referred to issues that are important, in the context of health promotion, to users. The issue of public health policy is extremely important. Primary care centres represent a vital step in the right direction. However, there are so many other things that can be done, particularly in the context of lifestyle, in order to improve the health of the population. This is not really limited to health care; it also relates to how we build our cities and organise our housing estates and how people travel. However, that is entirely another area.

We referred earlier to user involvement. If the committee is considering the type of services that would benefit both men and women, it is important to consult them. People should be asked about the services they would like primary care centres in their areas to provide. There may, as one of the members stated, be areas with particular needs that are not common — some needs are universal but there may be others in respect of which specialised services would be required. A user-involvement model might be adopted and people could be consulted. This would allow people to indicate the type of clinic they want in their area.

As far as I am aware, the HSE has not contacted us to date in the context of consultation. However, we would be very happy to work with it and make an input into its deliberations.

Ms Geraldine Luddy

Deputy Reilly referred to training and whole-time equivalents, this is a major issue and it will become increasingly important in the context of the number of GPs available and also the type of services that will be provided. When we examined the position with regard to sexually transmitted infections, we discovered, in the context of reproductive or sexual health issues, a reluctance on the part of some GPs — male and female — to deal with this matter with their patients. In addition, patients have their preferences. For example, a male patient may prefer to speak with another man in respect of problems he may be experiencing of an intimate nature. One of the key points in this regard relates to training for both sexes in the context of issues that are of a sexual nature, violence, etc. It is not easy for any of us to discuss such matters. Professionals will certainly require training in this area.

With regard to the issue of finance, there is no quick fix for primary care centres. It will take place over time and it will require resources. We will not be able to do it cheaper if we proceed with primary care. There will be better health outcomes at lower costs. It is cheaper overall than the hospital system but resources are needed and it will not be a quick fix. Even though at this time how every penny is spent is important, sometimes in a recession where we are examining priorities, it could be time to restructure the system in the medium to long term to give us much better outcomes and cost effectiveness.

Deputy James Reilly

With regard to sexually transmitted diseases, there is a great reluctance on the part of those affected to visit their local GP because of the insurance forms that must be filled when they apply for life insurance to take out a mortgage. They are afraid that will show up and, therefore, they like to go elsewhere. Does Ms Luddy favour tax incentives to make primary care a reality because, at the rate we are going, it will be 2050 before this is rolled out nationwide, given that we started in 2001?

Ms Geraldine Luddy

The evidence is that a tax for all with a universal health system provides the better outcomes and equity of access. That could be done through social insurance schemes or taxes. There are numerous ways to look at that.

Deputy James Reilly

That is helpful because I believe in universal health insurance and it is Fine Gael policy. However, what about the development of primary care centres, which has been talked about since 2001? One contract has been signed after all these years. What is the delegation's view on giving tax incentives to professionals and developers to make this a reality? At the rate it is going, it will be 2050 before the strategy is rolled out.

Ms Alessandra Fantini

We have not looked into that area in as much detail. We have not conducted a financial analysis. The health service has a bizarre system of incentives for delivery of care in inequitable and inefficient ways. Perhaps those could be examined and rectified first. We are not finance experts.

Chairman

I thank the council for its presentation and I thank the members of the delegation for dealing comprehensively with the questions. Their contributions were informative and helpful.