The health service-truth and fiction
By the Doctors Alliance for Better Public Healthcare*
There has been considerable discussion over recent months about the Irish health service, and the reasons for the current difficulties.
When attempts are made to discuss the origins of complex problems, within the setting of a brief news bulletin or time-constricted current affairs programme, the issues are often simplified for ease of discussion. This may be done by taking one aspect of the problem and discussing it at length, as though it were the source of all the difficulties.
This approach runs the risk of gross oversimplification, which then hinders progress to a general resolution of the problem.
This approach also runs the risk of alienating many of those directly involved, by making assumptions that on closer inspection are indefensible.
Some of the oversimplifications that have been generated over the past months about the Irish health service are outlined below, as a series of 'Truth' and 'Fiction' statements.
PUBLIC versus PRIVATE MEDICINE
Private medicine is superior to public medicine. Private hospitals will solve the A&E crisis. Public hospitals are in crisis because they are inefficient.
Most people believe that if you pay money, you get a better service.
Public hospital care is of high quality and is accessible free of charge to all citizens as a statutory right.
The public health sector is in urgent need of targeted funding to address the lack of clinical staff and essential equipment. Inefficiencies are caused by poor management, excessive bureaucracy and outdated equipment.
It is true that private hospitals in Ireland may provide more rapid access to certain types of health care - usually those requiring procedures / operations, because planned procedures are profitable.
However, in general private medicine does not provide emergency or urgent care which makes up the overwhelming majority of cases treated as in-patients in public hospitals.
Private medicine has limited ability to provide intensive care, and may not be in a position to cope with complications arising from the treatments it has provided. Patients with urgent illnesses or complications are admitted instead through A&E into public hospitals. It is too expensive for the private hospitals to maintain the higher staffing levels and stand-by staff which are necessary for urgent and emergency care.
Private medicine does not provide integrated rehabilitation for patients who have suffered a major illness (such as a stroke) and require multidisciplinary care.
Private medicine in Ireland cannot provide superior care for long term chronic illness such as emphysema, bronchitis, heart disease, diabetes, or for neurological conditions like epilepsy, multiple sclerosis, and motor neurone disease, or patients with dementia.
Most patients admitted as in-patients to public hospitals are not suitable for care in a private hospital, including most patients admitted via A&E. That is why there are patients with top level health insurance on trolleys in public A&E departments while there are beds empty in nearby private facilities.
Private medicine in Ireland cannot currently actively engage in preventative health measures such as population-based screening for common diseases which benefit the community at large.
Perhaps of greatest concern is the recent entry to the Irish health sector of 'for profit' healthcare, for which the finance act of 2002 has provided generous tax incentives. 'For profit' health care drives up costs, and has little impact on the general health status of a population, particularly when parameters of population health are measured (e.g. infant mortality and life expectancy).
This is evidenced by international comparison of health care systems. Expenditure on private medicine in Sweden is 1.4% of GDP, comparable to that in the UK, Japan, and New Zealand. In the US, it is 8% of GDP. Notwithstanding, Sweden and Japan have the lowest reported infant mortality rates in the world, whereas the United States ranks 18th . Life expectancy in the USA is 77 years, in Sweden it is 80 and in Japan 81.4
Introducing 'for-profit' health care in Ireland is not going to solve our problems.
The problems identified within the public hospitals are caused by consultants doing too much private practice.
Most people think that boosting activity in the public sector, and increasing the number of people treated publicly, is wholly under the control of consultants.
Renegotiation of contracts for all front line staff including consultants is required to make the hospital system more efficient.
There is no evidence to support the view that consultants' work practices or contracts are wholly or even mainly to blame for the current shortcomings in the public sector.
The work practices of all frontline staff must be integrated in a patient-friendly manner. However, the problems within the public hospitals relate primarily to a shortage of beds, outpatient facilities, operating theatres, specialist nurses and other essential services required to provide a high quality service within the public sector.
It must be recognised that changing consultants contracts, (including their entitlement to undertake private practice), will not cure the overcrowding in A+E, the long delays experienced by people on waiting lists for conditions not eligible for the NTPF, or the absence of nursing home spaces for people under 65 waiting up to 12-18 months in public hospitals for long term care.
Neither will this address the difficulties GPs experience in managing people with ongoing health care needs who require an integration of care between hospital and community.
Private patients are preferentially admitted to public hospitals.
Most people think that if you have private insurance, access to public hospitals is speeded up. Most people think that this works to your disadvantage if you don't have insurance.
75-80% of all admissions to public hospitals are admitted through A+E. Patients are admitted because they need urgent or emergency care.
Up to 50% of all patients in public hospitals have health insurance and could thus be designated as 'private', because at least 50% of the general population has private health insurance.
This is higher than the 20% 'cap' that was originally imposed on public hospitals.
The cap was lifted as it was unofficially recognized that the public hospitals, which have been chronically underfunded by the Department of Health and more recently by the HSE, depend on the income from private insurers to fund essential services.
The vast majority of these patients are admitted through A+E.
Thus, the conjecture that private patients are 'blocking' public beds in fallacious, as is the supposition that half of the people who find themselves suddenly and acutely ill and happen to have private health insurance can be safely transferred to and treated in a private hospital.
Everyone has a right to care in a public hospital. No-one can be refused admission and sent to a private hospital just because they have health insurance.
FUNDING WITHIN THE HOSPITAL SECTOR
Sufficient funds are being spent on the health services. We have more nurses per capita than anywhere else in Europe, and the amount of money going into health is sufficient to provide a high quality service.
Many people think there is no real funding problem any more. The figures commonly used show that our nursing ratios compare well internationally.
The public health sector continues to be under-funded, particularly with regard to people working directly with patients ('frontline staff'), equipment and facilities. Nursing ratios are not good either.
In Ireland we include some parts of the social service budget under health spending. According to OECD figures, up to 20%, or approximately ¤2.5 billion, of our 'health' budget is spent instead on items which are paid for from the 'social care' budget in other countries. Thus the total % of GDP on health is distorted upwards for comparative purposes.
We are spending more now on health than ever before. But we are still catching up on historic deficits, especially in buildings, machinery and replacing the hospitals wards which were closed in the 1980s and 1990s. While the statement about nurses might appear to be true at first glance, in other countries nursing duties are undertaken by care attendants (not qualified nurses).
In Ireland, all this sort of care is undertaken by qualified nurses, many of whom work part-time.
What should be compared with other countries is the total number of individuals working full time and performing nursing duties.
Using these corrected measures, we do not compare well with other countries, especially in the stressful front line work in our hospitals.
Mechanisms to develop front line services are excessively bureaucratic. It is also the case that this excessive and tortuous bureaucracy is often cited as the reason why health should be privatised.
While this may appear attractive on first inspection, there are real concerns that 'commercialisation' or 'commodification' of health will lead to a decline in services that do not generate profits.
Care packages across the board have increased, thus enabling more elderly and disabled people to be discharged from hospital with good community based support.
Because we now hear a lot about the shortcomings of nursing homes and the merits of 'care in the community', many people think that resources are available to care for people who don't need to be in hospital but who are not able to look after themselves, or who need support to stay at home rather than seek nursing home care.
Funding for care packages for the elderly has slowed down considerably.
Care packages for the under 65s who are chronically ill have been discontinued in some areas.
Funding for care of the elderly at home and within the community is almost impossible to access - unless it is to expedite discharge from hospital.
Most acute hospitals continue to have a high occupancy rate of people who are too disabled to return home.
Shortages of suitable nursing homes remain a major hurdle.
The length of waiting time for specialist consultation / admission has decreased.
Most people are aware that waiting time for surgical procedures is now supposed to be capped, and that the National Treatment Purchase Fund (NTPF) can be accessed if public waiting time is too long for certain procedures.
The waiting time for outpatient clinics, the most important way to access the system is not currently being measured in a systematic way.
People have to wait for a long time to see some specialists. This is because there is a shortage in some areas, notably neurology, rheumatology, urology, neurosurgery and many others.
The failure to address these shortages is due to delays in the approval of consultant appointments.
For example, despite the publication of a review of neurological services in 2003, which recommended a 400% increase in numbers, only five new consultant neurology posts have been appointed over the past four years, increasing the number from 11 to 16. The last new appointment in neurology at the National Neuroscience Centre at Beaumont was 11 years ago, despite the recommendation by Comhairle na nOspideal in 2003 that the current three posts should be increased to eight.
In many areas, the waiting times for admission to hospital have increased, particularly for patients with conditions that are not eligible for management by the National Treatment Purchase Fund (NTPF), or not suitable for treatment in a private hospital.
This is because 80% of all admissions to public hospitals come through A+E. There are not enough wards in our hospitals for both the urgent cases through A&E and the planned or 'elective' cases, so the planned cases are cancelled until they in turn become urgent or emergency cases.
The real waiting time from the point of GP contact to the point of enrolment in a hospital based clinic can be months or even years for some specialties.
The National Treatment Purchase Fund (NTPF) has solved the waiting list crisis.
The NTPF is structured to provide services to a very small proportion of the population requiring medical attention.
The NTPF provides funding for operations. It is not structured to help people gain access to medical services that do not have a 'procedure' component.
However, the majority of people attend hospitals not because they need an operation, but because they need medical management.
Not surprisingly therefore, it appears that the NTPF is now having difficulty finding suitable patients to refer for treatment. Despite significant increases in funding, the number of patients referred for treatment has remained low, even though the NTPF budget is now equivalent to 1.5% of the budget of the National Hospitals Office.
In 2004, with a budget of €44 million, the NTPF treated 14,000 patients. In 2007 on a budget allocation of almost €90 million, the NTPF expects to treat 17,000 non-emergency patients and a small number of outpatients.
While providing funding for people who have had to wait to for a long period of time for an operation is clearly of benefit, the NTPF as currently structured will make little impact on over-crowding in public hospitals which will treat over 1 million discharged patients (elective and emergency) and over 2.5 million outpatients.
'Waiting list initiatives' in public hospitals, as undertaken in other countries, would be a more equitable use of resources.
There are more than enough beds. MRSA is caused by doctors not washing their hands.
Most people think that public hospitals are dirty, that the hygiene standard of health care professionals is suboptimal, and that MRSA occurs because of this.
MRSA is a direct consequence of the bed shortage.
MRSA infections occur when people are sick and vulnerable. Infections are more likely to occur when hospitals are overcrowded and where there is a limited availability of isolation units.
While the rates of MRSA are not available for either public or private hospitals, public hospitals are open to public scrutiny through the national hygiene audit.
The abiding truth about MRSA, and many other problems in the Irish health system, is that there is a shortage of acute beds in appropriate settings.
It must be noted that the number of beds in the Irish hospital system was reduced by one third, from 18,000 in the 1980s to 12,000 today while the population has risen by 25%.
The number of acute hospital in-patient beds is no longer adequate for current acute needs, which is why A+ E units are always full and overcrowded. Reports from the Department of Health suggest that 15,000 acute hospital in-patient beds are needed.
Hospitals are most efficient if operating at 85% capacity, and public hospitals are currently operating at 110% capacity. As a result there are inadequate isolation facilities in all of the public hospitals.
Answer: While hygiene audits are important, we urgently need more beds in the acute sector.
ACCIDENT AND EMERGENCY
The A+E crisis is caused by bad work practices in hospitals. Penalising the hospitals with the most overcrowding will fix the problem.
A+E overcrowding is a symptom of the overall crisis within the health service. It is directly related to poor planning.
The practice of financially penalising the hospitals with overcrowded A+E departments is indefensible. Such sanctions exacerbate the problems within the hospitals and further compromise essential patient care.
In order to avoid budget penalties, hospital administrators are forced to focus on the patients in the A&E department even if it means overlooking the clinical needs of other patients who may be more ill. Consultants come under pressure to discharge patients too quickly from the wards in order to fit the next patient in.
Hospitals regularly refuse to accept critically-ill patients from other referring hospitals even though the patients can only be treated in a specialist unit. Even though these are very ill patients who have been prioritised between consultants, they are refused admission because other patients are on trolleys in A&E. Administrative decisions override the clinical decisions.
The main factors leading to overcrowding in A+E are:
1. Insufficient acute bed capacity
2. Inadequate facilities for long term chronically ill. 40% of bed days are taken up by 5% of patients
3. Inadequate resources within the hospitals to provide medical assessment units
4. Inadequate resources for primary care, with limited funding for out-of-hours GP services in some areas
5. Inadequate development of services that would allow general practitioners to directly access essential diagnostic services (like CT scans and endoscopy)
6. Poor integration of hospital and general practitioner services, including communication structures (email, 'hotline' telephone systems to the appropriate hospital-based service)
7. Not enough liaison nurses, physiotherapists, occupational therapists and social workers both in hospitals and in the community.
1,500 new consultants will solve all the problems.
Most people think that by increasing the number of consultants, the problems of access to public services will be solved
Without the physical space, administrative support, beds, theatres and staff to run them, new consultants will be unable to make a significant impact.
The ceiling on recruitment makes it virtually impossible to introduce new clinical services or expand existing services.
However, appointing consultants without appropriate facilities will only serve to compound the current problems.
We know that there is already a shortage of acute beds in the Irish hospital system.
There are numerous examples over the past 10 years of consultants who are appointed without appropriate facilities, who rapidly become demoralised with the public sector as a result and turn to the private sector, or who resign and return overseas.
To facilitate an expansion of consultant numbers extensive capital investment will be needed, including increased bed capacity, theatre capacity, theatre equipment, day ward facilities, out patients, etc.
Expanding consultant numbers will also have an impact on other people working in the health sector. There will be a need to invest in clinical staff, including specialist nursing, radiographers, technologists, physiotherapists, occupational therapists, speech and language therapists, dieticians, clinical psychologists, social workers, and other support staff. There will also be a need to increase the number of front line administrative staff including secretaries and other clerical workers.
REFORM OF THE HEALTH SECTOR
The HSE has instituted a programme of reform. This programme has been carefully planned with input from all health care professionals, and that includes a detailed plan about how the reform will be funded.
The programme of reform enunciated by the HSE is well-meaning and if correctly implemented would improve services for patients.
One of the major concerns that is currently being expressed by all front line staff in the health sector is that there has been very little consultation about how this proposed reform should happen. While the HSE may have employed external consultants to assist in the process of planning, there has been a notable absence of discussion at 'ground level'.
At present, the programme for reform enunciated by the HSE is strong on aspiration and weak on details of how it will be implemented. The proposals lack clarity and transparency.
The aspects of reform that are most needed include the provision of extra personnel and infrastructure at the frontline (points of patient contact).
This has not been seen as sufficiently prioritised, as judged by those working in the clinical areas at community, GP and hospital levels.
*The Doctors Alliance for Better Public Healthcare was set up recently to campaign for improvements in the public health service. The above article is part of a discussion paper drawn up by the Alliance.
Discussions on this topic are now closed.