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Health: where to from here?
by Fergal Bowers
Days on trolleys in A&E, tragic failings in hospital care, idle theatres, long waiting lists for operations and unprecedented public bust-ups between the Health Minister and medical organisations. These are just some of the symptoms of an ailing health service.
Today, more money than ever is being spent on our hospitals and the family doctor service, and yet, public dissatisfaction with the health system has never been greater. The Government has placed much hope in its reform programme and now public expectations have been raised further with the improvement in the State finances.
The public is tired of Review Groups and Strategy Reports and wants to know why the service is not delivering, who is to blame and what is to be done about it. Is the crisis about funding, bad management, a failure of policies - or a mixture of these?
The Cabinet reshuffle and the expected appointment of a new Health Minister could be an opportunity for the Government to look again at the Hanly hospital reform plan, health policies and its relations with health staff. Already Government sources are talking about increasing spending in key health areas and tackling the big problems but have we heard this all before?
Where has all the money gone?
The health service receives nearly one quarter of all Government funding. This year, it will cost over 10 billion euro to run. There is a widespread perception that despite the significant extra sums of money being provided for health, the effects have not been visible in A&E, on hospital wards and in the community.
According to the 2003 Brennan Commission report, health spending increased by 125% between 1997-2002. The challenge has been to ensure that the quality and quantity of services that people receive match that investment.
Every taxpayer pays around 6,800 euro a year for the health service. Most of the money goes on salaries for the 100,000 people who work in health. It is a labour-intensive service and the salaries for senior nurses, consultants and senior hospital doctors are high. Indeed, Irish consultants and junior doctors are one of the highest paid groups in a European context the Health Minister, Micheal Martin says.
Despite the criticism of the health service, the extra funding has produced some real results. Over 15,000 people on long waiting lists have been treated under the National Treatment Purchase Fund. More people are being treated in casualty, as inpatients and day patients than before. Some waiting lists, while very high, are reducing.
Slow pace of change
However, the pace of improvement has been too slow. “Taxpayers do not necessarily resent spending 6,800 euro per annum of their money on treating public patients”, according to Professor Niamh Brennan, who chaired the Brennan Commission. “They do resent their money being wasted. Therefore, before taxpayers are asked to spend even more money on the health services they are entitled to better assurances than are currently possible that their hard-earned money is well spent”.
This has been one of the issues regularly cited by the outgoing Finance Minister, Charlie McCreevy during his highly-publicised battles with Minister Martin on health funding. The question is - will the departure of Mr McCreevy to the European Commission in the autumn see a relaxation on the health purse strings? Minister Martin said recently, after the news of the departure of McCreevy, that they had “paced up and down outside his office in Finance, often in exasperation”.
While much more money is being spent on health now, historically, the funding has been low. As a result, it will take many years of significant investment to build the capacity needed to meet the demands. The Health Minister admits that in 2003 and 2004 the health service has been funded largely to maintain existing levels of service, with little or no money for new services.
Wastage
The Government reform programme is aimed at making the system more financially accountable and better performing. According to a recent report from the OECD, Ireland ranks 14th in the league table of developed countries in terms of the amount of money spent on health per person.
There has been considerable wastage. GPs have been paid for ‘ghost’ patients, due to errors in health board medical card lists. Hospital charges have not been collected. Health boards entered into contracts worth around 115 million euro not approved by the Department of Health. Accounting deficiencies were found by the Comptroller and Auditor General in many of the audit reports for many health boards. A fundamental recommendation of the Brennan Commission is that all costs incurred should be capable of being allocated to individual patients, so that the money trail can be seen. Tanaiste Mary Harney has made the point that up to now, “money has come before reform”, when both have to go hand in hand.
The conclusion - the ailments in the health service go much deeper than a shortage of funding.
Management flaws identified
While many other European countries have moved towards more decentralisation of the health system, Ireland is heading in the other direction. The argument made by the Department of Health is that after over 30 years of a decentralised system, it has not worked here.
The health service reform plan will see a more centralised management system under the new Health Service Executive and its all-powerful Chief Executive. The duplication of health agencies and services with 65 different agencies managing the health services is ending. A whole cultural change is proposed. Much of the problem is summed up by the following observation by Professor Niamh Brennan:
“Unfortunately in every single aspect of the health services the Commission examined, low standards of accountability and a complacent and casual attitude in this respect from the public servants in charge of taxpayers’ monies were found”.
Previously, the 2001 Deloitte & Touche Report on the health system, commissioned by the Government, found that the Department of Health had little or no personnel with experience in financial, statistical or social analysis, strategic planning, health economics or people with direct experience in the health service. A rather damning finding.
The culture among health boards has been one of competition rather than co-operation, little sharing and learning. The existing management system has failed.
Vested interests in battle
Health is an area with strong vested interests, many keen to maintain the status quo. Minister Martin has strongly criticised medical organisations representing consultants and GPs for what he argues is a failure to engage in reform talks. They in turn say that he has failed to deliver on commitments and that health service management is at fault.
The last major confrontation was with nurses and the strike of 1999. However, a landmark report by the Labour Relations Commission since then has pointed to the low morale among health staff and the high level of industrial relations disputes.
Doctors, because of their position, have many opportunities to go public on what they say are service failures and their claims will receive extensive coverage. Public polls show that people trust doctors much more than they do politicians. The Health Minister made the point during the week that medical unions primarily are interested in the pay and conditions of their members.
GPs have a large patient base and indeed some have made use of this to enter local and national politics. The health sector is an area of intense competition between health unions and life and death issues in hospitals make for big headlines.
Big headlines
Because of the nature of their work, doctors and nurses have first-hand knowledge of problems and can publicise these often for strategic advantage. The battle over the Hanly Report is a clear example of the power of local vested interests and how senior doctors can challenge Government policy.
Martin- leaving health?
Of all of the health groups, hospital consultants are among the most powerful. These highly-skilled, well-paid professionals are a fundamental element of the hospital system. While the Government has signaled recently that it intends to take on this group, a difficult battle is likely. One of the ways used to soften-up public opinion against doctors’ reported failure to engage in reform is to publicise their salary levels. This was the case recently when the medical card fees paid to certain named GPs were leaked. The General Medical Card Payments Board which manages the scheme says it did not leak the figures but it did give the full list of GPs’ fees to the Department of Health. The Health Minister says his Department did not leak the figures.
The Government also wants consultants to enter into new contract talks, however they are refusing because of a row over a deferred pay review and the manner in which their malpractice arrangements were unilaterally changed earlier this year. Without consultant support, the Hanly and other reforms are in serious trouble.
A ‘blame game’ appears to have broken out recently over the health service problems, with patients caught in the middle. With the hours of junior doctors due to be cut by law to no more than 58 a week on August 1, there is still no agreement on how it can be done without hitting operations and clinics and with no agreement with junior doctors.
Politics and the portfolio no-one wants
The Health portfolio is one of the most difficult in Government. It has been described as a basket of grenades and history shows that the Department of Health can damage political careers. On the one hand, the Health Minister is taken to task for day to day events in hospitals which he may have limited control over. The Minister is asked to intervene in most local health issues. When an Expert Group is appointed to examine an area in health, the Minister must decide whether to accept the recommendations and then has to work at Cabinet to secure funding needed.
If a Minister fails to intervene in a local health issue he may come under fire, if he does intervene he may be accused of being too interventionist. Any attempt to ‘downgrade’ a hospital will always face stiff opposition. With health issues, emotions can run very high. The local politics of health was perhaps best evidenced last year when Fianna Fail TD, Tony Killeen took part in a protest march in Ennis over the future of the hospital under the Hanly plan. Even divisions within Cabinet appeared to surface on Hanly and it was a factor in the local election results in certain areas.
Opposition politicians can often fuel local fears but do not have to make the hard funding and policy choices.
It is not without some irony that the Hanly Report said that a repeated concern expressed was “the influence of politics, whether local or national on decision making in health services generally and hospital services in particular”. The concern, it said, was that some of the more important decisions about the location and the type of service provision “appeared to be made on the basis of narrow sectional interests rather than on objective measures of service need, quality and patient care”.
Meetings in private
The ending recently of the health boards and having local representatives, doctors, dentists and other professionals as members was seen as a way of reducing local politics in health. The danger is that local democratic input is gone and there may be less transparency in how the system works. The meetings of the new Health Service Executive are to be held in private, unlike health board meetings.
Will the departure of McCreevy mean more money for health?
It will be interesting to see how much independence and power the new Health Service Executive will have and to what degree it may be subject to control by the Health Minister and Government, when some of the tougher decisions on hospital services have to be made. A report to the HSE recently called for a clear division in law between it and the Minister and his Department.
Key problem areas
Health reform
Repairing the health service requires management and structural reform and not just extra investment. The appointment of the new Chief Executive of the Health Service Executive, expected now around August, will be perhaps the most important appointments in recent years in health. The Brennan Commission recommended an international trawl for a person of suitable expertise, the clear message being that to appoint someone in Ireland from the ‘old’ system would be unwise.
Critics of the reform plan say that it will mean the same faces working in organisations with new name plates –rearranging the chairs on the Titanic. The real test of the reform plan will be whether it ensures that patients get a better service and whether a new era of accountability and performance measurement is created.
Idle facilities
Over 400 million euro worth of hospital facilities, built using taxpayer’s money, remain unopened around the country. In an odd policy approach, health facilities are built and then the Department seeks money to run them.
The funding is not available to staff and equip these theatres, A&E units and other facilities at hospitals such as Cork University Hospital, South Tipperary General Hospital, St James’s Hospital in Dublin, James Connolly Memorial Hospital in Blanchardstown, the Ballymun Health Centre, Mayo General, Letterkenny General, Mullingar General and other facilities. If these were opened, it would relieve some of the pressure on services. The best the Department of Health can say is that it has an “understanding” with the Department of Finance to open some of these facilities on a phased basis over the next two years.
Extra beds
The Government has provided less than 600 of the 3,000 extra hospital beds promised under the health strategy. The lack of capacity in the health system is one of the fundamental issues raised in a succession of independent reports. More beds means more patients treated. To be able to put in place the extra beds, more hospitals and units need to be built. Advance planning is needed to deal with the growing and ageing population and the pressure this will place on health system.
Statutory complaints system
Patients have no redress to a complaints system, underpinned by law. Such a Statutory system has been promised by the Health Minister. It could help reduce dissatisfaction with services, resolve problems earlier and cut the number of costly court actions taken by patients.
Waiting lists
The exact number of people waiting for hospital treatment is unclear. Estimates put it at anything between 19,000 and 27,000. The Health Strategy promise that no public patient, adult or child, will have to wait longer than three months for treatment by the end of 2004 can not be met. However, the National Treatment Purchase Fund has managed to get 15,000 operations performed, keeping the waiting lists lower than they would otherwise be.
Uniform eligibility for services
There is no uniform entitlement to services in the country. Health boards have varied in their interpretation and application of various services. The rights of patients need to be clear and underpinned by law and applied universally, irrespective of where they live.
Junior doctors’ hours
Cutting the hours of junior doctors, as required by law, will seriously affect services unless a new way of working is found. The Government has promised to appoint an extra 1,900 consultants over the next ten years to help deal with the gap which will be created in services. OECD figures show that while we have a good number of nurses per head of population, Ireland is down the league table when it comes to doctors.
An extra 10,000 nurses and other health staff have been promised but only a small proportion have been appointed.
Delivering better care as a price for Benchmarking
Can the Government get consultants to work longer hours and more on the front line? Will the promise to have hospitals open longer hours and clinics held in the evenings and at weekends really happen, along with other reforms, in return for Benchmarking? The final Benchmarking payment is due in mid 2005.
Raising life expectancy
Irish men and women continue to have one of the lowest life expectancies in the EU. Cancer and heart disease remain the big killers. Significant investment in health prevention programmes has been recommended in many reports.
Family doctor service
It is widely accepted that the family doctor service is one of the success stories of the health system. There are no waiting lists in primary care. More people are seen by GPs each year than are seen by the hospital system. The GP service can play a big role in health promotion and in providing certain services in the community at less cost and complexity than the hospital service. Funding the Primary Care Strategy can help improve this area of services.
* Fergal Bowers is editor of irishhealth.com
Last Reviewed: 26th July 2004
Anonymous
Posted:
28/07/2004 08:12 |
| No one will will face up to the fact that the halth system needs radical reform, cutting away a lot of the dead wood, administration overhreads and takign too much pwer away from the hands of consultants. |
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margaret(breatnac) Posted:
28/07/2004 09:47 |
| Yes money / funding is not the real problem, it does indeed go much deeper. There is hugh waste, and inefficiency, and accountability.The crisis is, bad management, a failure of policies ,and no accountability. Huge wastage. When the country was "poor", the health service was about patients. And patient care was far superior to what it is now. Mal practice was non existent. Hygiene, disinfection, sterility was of the highest standard. The hospital environment was safe. This has all changed. Even basic hand washing, disinfection of beds, trolleys, walls etc, etc, etc almost non existent. Resulting in hospital acquired infections, and all it's cost. Postioning of patients to prevent pressure sores , and give patient comfort "old fashioned". Now mattresses, and cushions do that ???. No oral hugiene, or eye care etc for ill patients. Basic patient care of a very low standard. N Brennan is right,there is hugh waste, and no accountability. low standards of accountability and a complacent and casual attitude. There are way to many people in "management", so all can say it's not there area of responsibility, when in reality they accept no responsibility for any thing. And they don't want anything brought to there attention, so that they can say they did not know. The hospitals, and health service is in a terrible mess, with appalling low standards. But more money is not the answer. Yes more money will cover up the cracks for a while, and pull the wool over the tax payers eyes for a while , and make it so much easier, for the new minister of health. But it is a big waste. The waste and incompetence, and mismanagement must be addressed to bring about actual, real improvement. Getting rid of the ill-health boards, and co councellors was / is a start. But the reform must continue into hospitals, health centres etc, etc, Keep up your good work and service to the people and patients .The patients / tax payers deserve a proper health service and proper real patient care. |
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Anonymous
Posted:
28/07/2004 10:03 |
| While small hospitals in the country are being closed, the N.A.H.B. has paid e 8 million to buy St Joseph,s hospital in Raheny Is spending another few million to refurbish it. It is a 60 bedded unit. Does this make sense????. How many patients are there since they bought it? What has it cost to "run" and mantain since they bought it ? Is this an example of wastage ? |
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Anonymous
Posted:
30/07/2004 19:34 |
| Up till very recently I would have been of the opinion that the health service was in bits. That was until both my parents have recently had health problems and were dealt with speedily and efficiently by all the health professionals they came into contact with. I particularily have to commend the help the local health centre and district nurse has given them and in fact me, as I was almost at breaking point dealing them. They could receive more help if they would only get off their pedestals and accept it. There may be shortcomings in the present health system but I personally can not praise the PERSONNEL enough. Thanks to you all.! |
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liam(lcollins) Posted:
31/07/2004 23:43 |
| there is a simple solution, get rid of all public servants , because serve they do not, let everyone get whatever health services they want, and produce their recpits, pay their money into their wages and leave out the midle man out. |
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Anonymous
Posted:
03/08/2004 08:45 |
| But that, Liam, wouldn't actually ber a workable solution because there would be no-one to manage it. |
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Anonymous
Posted:
17/08/2004 09:05 |
| It is essential === vital that a competent person gets the top position, C.E.O. in the new health position, replacing the dead wood that was the "health" boards. It's essential that it does not turn into a reshuffle of the dead wood into the new system. And it's essential that all the layers of dead wood not be allowed to build up yet again. Only a fraction of the employees, paid in the health service, actually have worked. Accountability, transparency, ability, committment, moral courage, character is necessary. The new system must not be allowed to go down the same slippery slope as the "health" boards. Patients / communities / Patient's representative associations need to have good representation on the new system. |
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Anonymous
Posted:
03/09/2004 09:46 |
| The health boards are very selective in what they choose to see / not see, act on or not act on. For long years in health boards around the country long stay wards / homes / nursing homes etc were shockingly under staffed especially at night. Often one nurse responsible for 40 to 50 patients. And in some cases an attendant on a ward with 30 to 50 patients, and a nurse on a similar ward. And the nurse having to leave her ward to give out drugs on the ward covered by the attendant. Nurses have been high lighting this for years. But no one including the health boards were interested. Two people on night duty with 23 patients is excellent staffing. How many long stay wards in the Dublin region, or indeed through out the country can equal or surpass this ? And the dressing contaminated by faeces, while certainly not desirable, unfortunately at times is difficult or impossible to prevent. It happens in hospitals, in nurse /doctor training hospitals. Much worse is happening in major nurse/doctor teeching hospitals. Contaminated /unsterilised instruments used for internal examinations from patient to patient week after week. Sterile dressings cut with contaminated /unsterilised scissors, and wounds packed and dressed with this, Stitches /sutures cut /removed with a scissors used to cut off /remove a dirty dressing from a foot, an ulcer, or what ever. Is the possibly unavoidable soiling of a patients wound more serious than this. Not in my opinion. And while it should not happen and should be prevented if possible patients hahe accidents / falls /cuts in hospitals. And now there is a big issue about not restraining patients. And nurses are afraid to restrain a patient even when it is in the patients best interest, and safety. It is an issue that needs to be nationally and responsibly addressed, in the interest of patients and nurses. |
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john(VPH13931) Posted:
04/01/2005 23:29 |
| So Fianna Fail and Mary Hearney are reforming the ruinous dinosaur of waste,,jobbery, and incompetence called the " Health Service" If reform consists of giving 15,000 (and counting)highly paid health board administrators,etc their wages for life ,plus any new benchmarking bonuses that emerge during the coming decades ;Mary,pray tell the long suffering taxpayers of your little island/banana republic what Exactly is the point in all the waffle and spin about "reform" Next years bill will now have the cost of "reforms",whatever that may consist of- and all the old wastage added together! Aer Lingus had unwanted staff walking the corridors at Dublin Airport on full pay for the last 20 years. E.E.C. farm subsidy reforms,just announced, consists in pensions for life for farmers-and the subsidies have still not gone away.! If reform consists of a repeat of this exercise in our hospital administration offices,God help the suffering people who neglected to cast a vote to remove Fianna Fail from office,during the last general election. The coming years will bring new taxation, on a level that you have not even dreamed about. www.soldiersofdestiny.org |
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edward(ADX23795) Posted:
02/02/2005 00:26 |
| I believe it is time for the gov to give more funding to training of at least twice the no of doctors and to break the vested interests,or just hire more doctors.also it is time for a hospital to be a dedicated complentary medicine. people will have to rely on self help |
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Anonymous
Posted:
02/02/2005 12:03 |
| The reason why there is not more complementary medicine in hospitals is that it not considered empiracaly proven and many doctors are concerned about those without the same formal training, moving in on their patch. I take your point about vested interests but on the subject of doctors. The RCOS, relies heavily on the fees paid by those from overseas who wish to train as doctors, witht he result that many, when they are finished training, return home - leaving hospitals exactly as theyt were before - short of fully trained doctors. |
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Anonymous
Posted:
25/03/2005 18:10 |
| I think it's about time our government put some money into the mental health service, by training more psychologists. I currently work as an Assistant Psychologist and am competing against 150 very well qualified candidates to get Clinical Psychology courses every year. At the moment there are about 40 places in the entire country, including Belfast. 2 out of 3 Clinical Psychology posts are not filled because we are not training enough people. The demand is there, the students are there, it's about time we were given a chance to train and apply for decent jobs. |
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Anonymous
Posted:
14/04/2005 15:09 |
| Mary Harney should have to account for the disgraceful situation in our hospitals,this government are not having to answer to anybody they just do as they please,if they were in the UK they would be hounded by the media and the opposition |
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Anonymous
Posted:
12/05/2005 19:06 |
| They should bring back a medical specialist and clinic like other countries. This means that patients could have someone that can decide if the many treatments from many areas can be brought together to see if the drugs etc are not clashing. Please don't say that the GP'S can do this . They do not have the time. |
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Anonymous
Posted:
20/05/2005 16:50 |
| Bring back matrons,get rid of three quaters of admin,we certainly would have cleaner hospitals,and top priority would be given to the sick |
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Anonymous
Posted:
23/05/2005 11:16 |
| I agree with the 20/5/2005 How much has the new training of nurses effected the nurse/patient relationship. The uni training is not the proper way to select or train nurses at patient level. This is not a desk job. The uni training should begin after basic training and possibly after qualifying for the basic nursing. You have nurses that won't use there commonsense to look at all the records of the patient they now only want to deal with there own department. Also cleaners are only sub-contracted and they aren't in the hospital twenty four hours. |
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martin(IJV30004) Posted:
21/06/2005 21:57 |
| One chambers concise dictionary describes a minister as "someone who administers or proffers in service or kindness" and who is "the responsible head of a department of state affairs". Comment may be superfluous...but perhaps if several successive ministers for health had adhered to these 'maxims' we might not be in such a 'state of chassis'. |
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bigkev Posted:
23/02/2006 09:08 |
| Put the clinician into management Give the general practioners and their patients a firm role in commisioning local services diretly from the local hospital BASED ON LOCAL NEED Agree service provision with the local hospital and fund accordingly Stop centralising everything on the large cities Designate the city hospitals as centres of excellence and fund accordinally for instance have a samll number of highly specilised services at these units where patients will travel for care . Cancer being one move the other services back to the smaller district general hospitals have a system based on equality of access why should the patients from Cavan , Monaghan have to travel to the centre why not have the centre travelling to them . be adventerouse in your provision off services . what about mobile servvices shared on a cross border basis where the equiptment and staff are paid to provide a range off services cross border . M.R..I scanning to hospitals on both sides of the border who on theri own cannot afford the large invetment . i am full of ideas like this and know that they will work if we on both sides of the border tear down the little empires surrounding major care providers . Bbe innvative and solve problems more off the same and stay static Finally take the polititions out off health |
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bigkev Posted:
15/04/2006 06:32 |
| COME ON FOLS ANSWER ME LAETS GET GOING ARE WE NOT CAPABLE OFF DOING ANYTHING UNLESS WE ARE TOLD HOW |
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Gary(DIF46188) Posted:
04/05/2006 14:58 |
| I am a Canadian Senior Citizen living in the Netherlands. As a *survivor* living by managing my chronic pain .. etc., etc., I am now able to take up the reins again where I left off some years ago in Canada. With the powerful tool of the Internet, I am advocating globally for Health, Health Reforms, and closer to home ... people living with pain and mental distress. When reading over the articles, comments by professionals as well as *consumers* one thing clearly stands out. The focus is directed to the core (worldwide) ... the famous or maybe infamous bureaucratic .. "bottom line". I am not an economist nor a health professional. However, I did educate myself in the best school on this planet .... the School of Life. It would seem to me that more can be achieved, if perhaps we could bring ourselves to work together to take *action* rather than to expand so much energy with rhetorical statements! It is very clear to me that the problems are the same whether I am in Canada, U.S.A, Australia, India, Europe, China, all the countries I have lived and worked in. I have left out Africa, because this is one continent I only touched down on when travelling by aeroplane! Where ever I visited, it is always the same ... " Change what you will, just don't touch my turf!" People ... I think we need an attitude reform before we can achieve any other reforms ... health included! |
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Bright eyes Posted:
23/11/2007 17:34 |
| I have experienced a litany of inept, poor and painful response and assistance and hospital and expertcare with all of my multi-faceted disabilities. I was told I was only allowed contact the Occupational therapist at 9-10 in the morning, when I rang at 12 to say my wheelchair wheel had broken and it is Friday. She also put the phone down as I was shouting in desperation. I have so much wrong with me I am near a nervous break down. I have to fight for everything, and have pleaded for and need a counsellor to deal with my multiple problems. I keep telling the GP that the HSE are determined to see me on the bottom of the harbour. I have neurological problems, immune problems, mobility problems and am in extreme pain. I am severely deaf have sjogrens, hughes syndrome a query for Parkinsons, Dystonia and Chorea. |
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