General practitioner workforce planning: assessment of four policy directions

<p>Abstract</p> <p>Background</p> <p>Estimating the supply of GPs into the future is important in forecasting shortages. The lengthy training process for medicine means that adjusting supply to meet demand in a timely fashion is problematic. This study uses Ireland as a case study to determine the future demand and supply of GPs and to assess the potential impact of several possible interventions to address future shortages.</p> <p>Methods</p> <p>Demand was estimated by applying GP visit rates by age and sex to national population projections. Supply was modelled using a range of parameters derived from two national surveys of GPs. A stochastic modelling approach was adopted to determine the probable future supply of GPs. Four policy interventions were tested: increasing vocational training places; recruiting GPs from abroad; incentivising later retirement; increasing nurse substitution to enable practice nurses to deliver more services.</p> <p>Results</p> <p>Relative to most other European countries, Ireland has few GPs per capita. Ireland has an ageing population and demand is estimated to increase by 19% by 2021. Without intervention, the supply of GPs will be 5.7% less than required in 2021. Increasing training places will enable supply to meet demand but only after 2019. Recruiting GPs from overseas will enable supply to meet demand continuously if the number recruited is approximately 0.8 per cent of the current workforce per annum. Later retirement has only a short-term impact. Nurse substitution can enable supply to meet demand but only if large numbers of practice nurses are recruited and allowed to deliver a wide range of GP services.</p> <p>Conclusions</p> <p>A significant shortfall in GP supply is predicted for Ireland unless recruitment is increased. The shortfall will have numerous knock-on effects including price increases, longer waiting lists and an increased burden on hospitals. Increasing training places will not provide an adequate response to future shortages. Foreign recruitment has ethical considerations but may provide a rapid and effective response. Increased nurse substitution appears to offer the best long-term prospects of addressing GP shortages and presents the opportunity to reshape general practice to meet the demands of the future.</p

Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care

<p>Abstract</p> <p>Background</p> <p>Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument.</p> <p>Methods</p> <p>A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status.</p> <p>Results</p> <p>Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation.</p> <p>Conclusion</p> <p>Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words)</p

A national survey of chronic disease management in Irish general practice.

It is timely to look at how we deliver chronic disease care in General Practice, and also to consider what aspects of this we may care to change, to augment, to dispense with, or to maintain. The Chronic Care Model has broad international acceptance as a model to provide guidance on the shift from our current predominantly acute and episodic model of care to a lifelong model of promotion, prevention, early intervention and chronic care. The Chronic Care Model encompasses both non-communicable disease such as diabetes, heart disease, chronic obstructive pulmonary disease, cancers and depression and communicable diseases such as AIDS, and sometimes tobacco, alcohol and problem drug use are included. The core elements revolve around organizational changes in health care delivery – better connected teams with clinical informatics and decision support, proactive planned care around evidence, and patient and care giver specific needs with greater support for self-care. Many countries are engaged in the transition to a Chronic Care Model. These range from the West including the US, Europe, Canada, Australia, New Zealand,as well as Ireland to the developing world including China, India and South East Asia. However the transition in well established systems is difficult to make if initiatives are ‘top down’, particularly without patient centred approaches and physician leadership or active involvement. This study provides a baseline of the provision of chronic disease management in Irish general practice in 2010. • It compares Ireland to survey data of primary care physicians in 11 countries, allowing Irish general practice to be measured against international counterparts. • The study achieved a 72% response rate. • 63% of GPs believe that there are some good things in our health service but significant changes are needed to facilitate the management of chronic care. • GPs reported wide use of information technology systems within the practices. • 99% of respondents indicated that they provide an out-of-hours service for their patients, which places Ireland as the leader of provision of access for patients outside of surgery hours, compared to their international counterparts. • A small number of routine clinical audits are being performed. • Irish GPs use evidence based guidelines for the treatment of diabetes, asthma or COPD and hypertension, to the same frequency as their international counterparts. • The main barriers to delivering chronic care are an increased workload and a lack of appropriate funding for chronic disease management. • GPs are interested in targeted payments for the management of chronic disease. • 36% of respondents indicated that their practice was functioning as a part of a primary care team. • GPs’ perceptions indicate that they believe substantial differences remain between fee-paying patients and GMS entitled patients in terms of access to diagnostic tests, longer waiting times to see a hospital based specialist and longer waiting times to receive treatment after a diagnosis. • GPs perceive that their fee-paying patients experience difficulties in paying for medications and other out-of-pocket expenses. • GPs support the concept of shared care initiatives between themselves and local hospitals

A national survey of chronic disease management in Irish general practice.

It is timely to look at how we deliver chronic disease care in General Practice, and also to consider what aspects of this we may care to change, to augment, to dispense with, or to maintain. The Chronic Care Model has broad international acceptance as a model to provide guidance on the shift from our current predominantly acute and episodic model of care to a lifelong model of promotion, prevention, early intervention and chronic care. The Chronic Care Model encompasses both non-communicable disease such as diabetes, heart disease, chronic obstructive pulmonary disease, cancers and depression and communicable diseases such as AIDS, and sometimes tobacco, alcohol and problem drug use are included. The core elements revolve around organizational changes in health care delivery – better connected teams with clinical informatics and decision support, proactive planned care around evidence, and patient and care giver specific needs with greater support for self-care. Many countries are engaged in the transition to a Chronic Care Model. These range from the West including the US, Europe, Canada, Australia, New Zealand,as well as Ireland to the developing world including China, India and South East Asia. However the transition in well established systems is difficult to make if initiatives are ‘top down’, particularly without patient centred approaches and physician leadership or active involvement. This study provides a baseline of the provision of chronic disease management in Irish general practice in 2010. • It compares Ireland to survey data of primary care physicians in 11 countries, allowing Irish general practice to be measured against international counterparts. • The study achieved a 72% response rate. • 63% of GPs believe that there are some good things in our health service but significant changes are needed to facilitate the management of chronic care. • GPs reported wide use of information technology systems within the practices. • 99% of respondents indicated that they provide an out-of-hours service for their patients, which places Ireland as the leader of provision of access for patients outside of surgery hours, compared to their international counterparts. • A small number of routine clinical audits are being performed. • Irish GPs use evidence based guidelines for the treatment of diabetes, asthma or COPD and hypertension, to the same frequency as their international counterparts. • The main barriers to delivering chronic care are an increased workload and a lack of appropriate funding for chronic disease management. • GPs are interested in targeted payments for the management of chronic disease. • 36% of respondents indicated that their practice was functioning as a part of a primary care team. • GPs’ perceptions indicate that they believe substantial differences remain between fee-paying patients and GMS entitled patients in terms of access to diagnostic tests, longer waiting times to see a hospital based specialist and longer waiting times to receive treatment after a diagnosis. • GPs perceive that their fee-paying patients experience difficulties in paying for medications and other out-of-pocket expenses. • GPs support the concept of shared care initiatives between themselves and local hospitals

Peer support in type 2 diabetes: a randomised controlled trial in primary care with parallel economic and qualitative analyses: pilot study and protocol

<p>Abstract</p> <p>Background</p> <p>Diabetes is a chronic illness, which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self-management training for diabetes has been delivered in a didactic manner. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. This paper describes the pilot study and protocol for a study that aims to evaluate the effectiveness of a peer support intervention for people with type 2 diabetes in a primary care setting.</p> <p>Methods/Design</p> <p>A pilot study was conducted to access the feasibility of a randomized controlled trial of a peer support intervention. We used the MRC Framework for the evaluation of complex interventions. Elements of the intervention were defined and the study protocol was finalized. In this cluster randomised controlled trial twenty general practices are assigned to control and intervention groups. Each practice compiles a diabetes register and randomly selects 21 patients. All practices implement a standardised diabetes care system. In the intervention group all practices recruit three peer supporters. The peer supporters are trained to conduct nine group meetings in their general practice over a period of two years. Each meeting has a structured component. The primary outcomes are blood pressure, total cholesterol, HBA1c and the Diabetes Well-being score. In addition to biophysical, psychosocial, economic and health service utilization data peer supporter activity and qualitative data are collected.</p> <p>Discussion</p> <p>Peer support is a complex intervention and evaluating such an intervention presents challenges to researchers. This study will evaluate whether a peer support programme for patients with type 2 diabetes improves biophysical and psychosocial outcomes and whether it is an acceptable, cost effective intervention in the primary care setting.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN42541690</p