Waiting for change - will Reilly deliver?

[ by Niall Hunter, Editor www.irishhealth.com]

Now that we have bid a fond farewell to Barack Obama and Queen Liz, reality is knocking on the door as we hide behind the curtains.
 
We are still enduring an economic nightmare, and partly as a by-product of that, a health service that appears to be in continual meltdown mode.
 
The fanfare surrounding James Reilly's newly-announced but as yet pretty vague waiting list initiative will do little to ease the feeling that we are looking at the possibility of key aspects of our health service breaking down.
 
And this is not just in terms of acute hospital waiting lists.
 
For example, something must be seriously wrong with any health system that is forced to completely halt admissions to State-supported long-term care in nursing homes.
 
The problem is that across many parts of the system, thousands of people in need of care, either in hospitals or in the community, and their families, can no longer rely on the HSE and its services to help them when they are at their most vulnerable.
 
The health service, which was never functioning very effectively, is now in danger of grinding to a halt at key stress points.
 
The US President didn't hang around to give us the benefit of his own experience of reforming a dysfunctional health system.
 
Our still relatively new Health Minister is now tasked not only with implementing a gargantuan universal health insurance reform plan, but with plugging more urgent funding and organisational gaps left following the largely unmourned departure of his predecessor.
 
He has made a reasonably good start, particularly in decapitating the corporate board structure of the HSE and trying to make it more directly accountable to Government.
 
Dr Reilly's just-launched waiting list and A&E initiative, in the form of a Special Delivery Unit (SDU), certainly sends the message out that serious efforts are being made to improve acute hospital care.
 
However, there are caveats about how the necessary capacity to reduce treatment waits will be found and what will happen to people on waiting lists in the shorter term before the reforms kick in.
 
With the NTPF ceasing further commitments to treat patients until the SDU is fully in place, public patients relying on the old reliable waiting list as their main access point to acute care would have reason to be worried.
 
Their unease will not be helped by the Minister admitting that in the short-term at least, treatment waiting lists may grow before the SDU fully kicks in and A&E waits are tackled first.

If this plan goes wrong, it could turn into a bad Irish joke -   the waiting list initiative that made them longer than they were already.
 
One cannot help but be cynical about this - we have had such initiatives before that made little impact when faced with the dead hand of a dysfunctional system.
 
The dilution of the role of the National Treatment Purchase Fund (NTPF) will, however, be welcomed by many.
 
While it did make some significant inroads into tackling treatment waiting times by organising private care for public patients, it boosted private healthcare at great expense to the taxpayer and left the outpatient waiting list crisis largely untackled.
 
The NTPF in many ways perpetuated the 'paying on the double' two-tier divide in our healthcare system. Also, reduced bed capacity and job cuts in the public system allied to recent cuts in the NTPF's own budget have made it difficult for it to keep a lid on waiting list rises.
 
But will the NTPF’s effective replacement as a waiting list cure be any better?
 
A worrying aspect of the special delivery unit system is that it is to a certain extent mimicking the Northern Ireland model.
 
The Northern health authorities, in a recent change to their previous waiting list policy, also reduced reliance on using the private sector and concentrated on building up the public sector to tackle waiting lists. The result so far has been a spiralling of waiting lists across the border.
 
This would indicate that however much you try to introduce efficiencies, teamwork and other improvements, if the capacity is not there many people won't be treated on time.
 
With no extra funding made available other than what was already there under the NTPF, the capacity issue could cause Dr Reilly's initiative to fall at the first hurdle.
 
While the Minister admits it will take three years to fully sort out the waiting list crisis, it is to be hoped that his actions will start to show some positive results reasonably quickly.
 
Turning to another pressing issue, and let's not panic here or anything - our whole process of elderly care is basically facing collapse. In addition, the many who save the State millions by providing home- care to disabled and vulnerable family members are being hammered by cutbacks to home supports.
 
Apart from waiting lists and A&E, Dr Reilly's other big headache at the moment is plugging funding gaps and improving the administration of these vital areas of healthcare.

These issues have led to serious worries and stress for thousands of families.
 
In fact, the problems in the area of long-term and home care for the elderly and medically vulnerable epitomise the great 'lost opportunity' in making our health system better.
 
The time to reform how hospital and community care are organised, funded and interact with each other was perhaps 10 years ago, when the State's finances were healthier and a plethora of reform proposals were on the table.
 
It is very difficult to tilt the funding balance from hospital to community care without ensuring that both are funded adequately as the reforms take place.
 
Reform cannot really be done on the cheap, and the everyday imperatives of healthcare contradict the 'Harneyism' that an economic crisis is the ideal time to radically change things.
 
Dr Reilly is trying to improve and reform the system when the money has run out, and even the money that's there isn't being spent efficiently.
 
The Minister is faced with the typical ridiculous anomalies of bureaucracy, whereby people's home care support grants are unceremoniously cut, and the family member in need is then transferred to a care centre in which the care actually costs the taxpayer more.
 
There are other examples of these anomalies- for example, vulnerable elderly people who cannot get nursing home places due to funding problems may end up unnecessarily as emergency admissions through A&E, again costing the system more.
 
A disabled young adult being cared for at home is left to languish for years on a surgical waiting list. This means the surgery he eventually gets will be more complex and perhaps traumatic and will cost the health service more than if he had been treated quickly.
 
This is not just your typical bureaucracy, but sheer callousness.
 
The HSE should consider changing its customer charter to: 'if we can treat you at all, we promise to treat you in the wrong place at the wrong time at maximum cost to the taxpayer, and this treatment will be of dubious benefit to your health or quality of life.' Not exactly catchy is it?
 
These faultlines serve to damage people's lives.
 
The same funding anomalies we have heard about this week were being reported in the 70s, 80s, 90s and noughties, but nobody ever learns, or is encouraged to learn, from past mistakes.
 
Granted, as a country we no longer have largesse to dole out to the health service, but we should at least be spending the money we still have, courtesy of the IMF or EU, in a sensible manner.
 
Another issue is that despite what the Minister says, he will for some years still have to rely on a health executive that he must deep down have little confidence in to deliver change. Dr Reilly sometimes has the habit of fulsomely praising entities to which he has recently taken the axe. It's probably just good manners on his part.
 
However, you would be well-warned if the Minister starts to praise you - he may be about to abolish you.
 
Added to the above challenges, Dr Reilly faces the Everest climb of totally changing the care model by implementing universal health insurance in five years or so. Let's not even think at this stage about the complexities involved in that.
 
Right now, people would be happy if the Minister fixed things that should already be working reasonably well.
 
Dr Reilly has admitted, in outlining his plans, that at some stage he will have to stop 'talking the talk', and start 'walking the walk.'
 
Indeed, the feeling was growing that we perhaps have heard his dissertations and analogies of what is wrong with system a bit too much.
 
The time has now surely arrived for the good doctor to don his walking shoes and delineate how his short term and longer-term reforms will work.
 
Now that he has begun to set up structures that promise to deliver, including an entity that is actually called a delivery unit, the public will be waiting for Dr Reilly to 'do exactly what it says on the tin.'
 
After all, that's what people elected a new Government for.
 
Waiting lists may rise despite new plan

broken1  Posted: 14/06/2011 23:56

Health and care in the Irish context is scary stuff. if it was not for the ability for me to travel abroad to even get a diagnosis, i would still be shown the door by Irish doctors which happened for five years. I have many autoimmune diseases and a neurodegenerative disorder as does my twin. as two single adults on a medical card our daily thoughts are 'health provision' and 'housing and care provision' when we consider how to set about a day, half of that is in phone calls, internet for ways out of adaptive aids and such, and we are lucky if we get the rest of the day free of a doctors appointment, sorting out housing in order to do what most do, LIVE, we would get maybe a few hours a day at a semblance of that. not to mention worry...worry, when will the care packages we hope for kick in, will they be changed, loped or stopped. will my disab pension be stopped again, or tax and vrt exempt adaptive van costs. will it cost more for blue badge, tolls, or other. Will we get the needed physio (we are not at present), will we get the much needed powered chairs, chair lifts, home helps. will we get a decent supported independent living scheme. we are NOT right now.  Worry, and more and more of the same, to the point of us harassing for basics, literally basics. we are worn out, worn down, spent and lost in a sea of economic mess that is also impinging on our health services catastrophic chaos to say the least. Ms. Harney may not have been a doctor, but we had Dr. Drumm and now this guy. if my experience of doctors is anything to go by, i shall wait not with much enthusiasm.  to dwell on our health services makes me so unwell.. i grind the teeth (they are going too, slowly due to a condition that causes them to) but i have some left to grind. Not one single person in the whole of ireland helped me out of my severe social housing difficulties, i despair. but i shall do so with flair, colour and purple hats.  and spit.

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