Manifesto review 2 – health and the Social Democrats

I’ve now had time to read the Social Democrat’s health policy in their manifesto. Their overall goal is to create an Irish NHS, a single tier, comprehensive health care system, largely free at the point of use. This is a sensible, clearly described goal, which would improve health care in Ireland. The British NHS is not perfect, but it is a lot better than the Irish system, and a lot cheaper too. This forms part of their strategy to reduce the costs of living in Ireland.

There are three sections, one on acute healthcare, one on mental health, and one on disability services. Health care for older people is discussed as part of a broader section on support for older people.

The acute services section is labelled ‘BUILD AN IRISH NHS’. Ironically most of the text talks about hospitals, trolley waits, ambulances, waiting lists for surgery, travel for procedures. There is a stated aim to have a community care focus in the system, but it is not clear what this would mean. The practical measures listed include supporting staff, by, for example, encouraging the recruitment of GP’s and nurses, building more primary care centres; improving access by, among others, formal resource allocation methods, wider access to free GP care, aggressive health promotion, reducing administrative costs, and aligning hospital group borders and community health office borders; improve service delivery by setting up minor injury units, improved access to diagnostics technology both for A/E and for GP’s, and getting 5 chronic disease management programs running.

They also say ‘Implementation is as important as policy in health reform’ , with which I agree strongly! To support implementation, they will set up a long-term vision for health care, with staff and patients; work across all of government; make health service data more open, and remove perverse incentives. They also suggest reducing prescription charges for GMS users, in the first section of the manifesto.

All of this is laudable, and some of it may well be achievable. The idea of settling on a clear vision for the service is appealing, although more detail about how this is to be done would be welcome. It is still too hospital focused, and I do not think they quite get the scale of the resources required to resource general practice properly. There isn’t a clear commitment to free GP care, nor to the level of resources in general practice needed for this. Reducing administrative costs sells well to the public, but would probably prevent any effective change. As I never tire of saying the health services have too many administrators, but not nearly enough managers.

Under the heading ‘EMPOWER THOSE WITH DISABILITIES’ there is a strong and positive discussion of the issues for people with disabilities. The core of their policy is to ratify the UN Convention on the Rights of Persons with Disabilities, which would be very welcome. Other policies include supporting people with disabilities in living independently, in finding and keeping work, and in staying out of poverty. They don’t discuss the individualization of payments, where the disabled person, and not the service supporting them, gets state funding, and their vision does not really cover problems like high rates of imprisonment for people with intellectual disability, but the remainder would be a welcome new focus on disability care.

For older people, they suggest expanding the Fair Deal scheme to over home care packages, increasing access to medical cards for older people, and improving the benefits to carers of their PRSI contributions. Reducing prescription charge would also benefit older people significantly.

Under ‘SUPPORT MENTAL HEALTH’ they call for full implementation and resourcing of Vision for Change, the (very good) 2006 mental health strategy. They will expand services to detect difficulties in infancy, and to improve the mental health of school children. They will increase resources for suicide prevention, and support the much wider use of non-drug therapies for mental health problems. Additional ring-fenced resources will be set up for some high risk or marginalised groups, including young parents, Travellers, and asylum seekers. They will require a much greater emphasis on effective care for people with a ‘dual diagnosis’ – addiction and a specific mental health problem.

Overall, this is a reasonable policy. It’s not clear how much it would cost, which is a huge omission, but I think a process starting with developing a common vision for services, and with a focus on community care, might get us somewhere. At least implementation is discussed, which is unusual in political manifestos. There is no discussion of the need to fix the culture of HSE, nor of the need to improve accountability. There is not enough thought given to general practice, a blind spot shared with the Department of Health. Some of the proposals would not work – notably reducing health service administration, and aligning community health services to hospital group boundaries. However, all in all, this is a policy with many positive features.

Health policy in the Renua Ireland manifesto

I’ve just finished reviewing Renua’s health policy. I plan to review the health policies in each party’s manifesto as these become available. I’m fairly familiar both with the Irish system, and the health care systems in other developed countries, which gives me some basis for comparison.

My take is that the Irish health system is actually improving – it’s much better run than five years ago, and much more transparent about what it is doing, and what it is not doing, but there is still a lot of work to do. For me, the big challenges facing it are three :-

  • a steadily rising number of older people (about 20,000 extra people over 65 each year). These people are pretty healthy, but they do place extra demand on health care.
  • it was built to provide acute care, both in hospitals and in general practice, but most of the need is now for long-term care for chronic illness.
  • it is expensive, and not meeting our needs right now. Fixing this, will cost a lot of money, certainly at least another billion euros a year, just to stand still. Changing the system to meet these needs more efficiently will also be expensive, but is probably more sustainable.

The bulk of the costs go to two groups, a small number of people in long-term institutional care, and a rather larger number of people affected by more than one long-term illness. The health service is not coping with these needs. This is partly because of resources, with large budget cuts from 2008 to 2014, and effectively flat budgets since; and partly due to the model of care we have, which is still heavily focussed on acute hospitals, and leaves general practice and primary care starved of resources.

Renua’s summary of their health policy is this :- ‘Healthcare must protect patients and treat them with respect. We will re-focus the health system on realistic and deliverable targets. We will deliver multi-disciplinary primary care, relieving pressure on acute hospitals and ensuring greater access to the care patients urgently need’.

All of this is eminently reasonable, but the details behind it matter. They do propose a patient centred health service, ‘shaped and designed around the increasing participation of citizens in the management of their health’, but give few details of how this is to be done. They also want to deploy electronic health records, which has to be a good idea.

They have one really good idea – a National Health Forum, where a vision for our future health services would be produced. Tony O’Brien, in a recent interview on the Sunday Business Post, lamented the lack of a common national vision for health care in Ireland, and such a Forum might allow one to develop. The forum would develop, and maintain, a rolling 20 year needs assessment for healthcare (necessarily broad brush and high level), and develop plans for the use of ICT and health care management. Such a body, providing it was taken seriously by the Civil Service, and the Minister, could be very valuable.

There is also one huge hole, which is the source of funding, and the route by which funding reaches health care providers. This is not discussed anywhere, and it’s an enormous omission from any serious health policy.

For acute hospitals, they propose establishing the Hospital Trusts properly, which is a good idea, and encouraging both competition between them and ‘deep specialisation’ for elective work. Neither of these has a reasonable evidence base. Competition between hospitals does not contribute to positive outcomes for patients, and encourages various exotic games, including the shifting of high cost patients. There is good evidence that volume and outcomes are linked for many procedures, but there is a big risk, that the volume of simple cases will be taken by some providers, leaving others to deal with all the complex, costly cases. This can seriously destabilise healthcare.

In general practice, they propose much greater use of GP services, which is good idea. However, some of the pieces of this seem poorly though out, for example, hiring doctors to assist GP’s (why not more nurses who do this already. and are trained?) ; putting consultants in the community, a move for which there is no evidence; and deploying a range of mobile clinics providing different services.

For people with mental health difficulties, many of their objectives are good, but again, there is little specific detail about how these will be reached. Recovery is not mentioned, nor is mental health advocacy, both very important parts of mental health systems.

For older people, they advocate more access to home care, and access to care in supported housing, with less emphasis on long-term institutional care than at present.

Oddly enough, two of the longest sections of the policy, are one on self-insurance against medial negligence, the scheme used in Denmark, and one on a healthcare professional indemnity Act. Both are interesting, but they seem unbalanced, and perhaps out of place in a manifesto.

Overall, it is clear that their hearts are, more or less, in the right place. There is a welcome emphasis on GP’s, preventive care, mental health, and on primary care. There is a complete lack of detail on funding, payment mechanisms, and the overall resources, which is worrying!

Saving General Practice and Irish Healthcare

The IMO organized a meeting on Wednesday evening in Buswell’s Hotel in central Dublin, just across from the Dáil (the Irish parliament building) on the topic of ‘Solving the Chronic Disease Problem – through General Practice’. It was packed out, and there was a very good line up of speakers, starting with Leo Varadkar, who trained as a GP and is now the Minister for Health, and including three prominent GP’s Austin Byrne, William Behan, and Tadhg Crowley. We also had spokespeople from a selection of the political parties, Sinn Fein, the Social Democrats, Fianna Fail and Fine Gael there.

The problem

Ireland has a very young population by EU standards, with a low proportion of people aged over 65. However, that proportion has been growing rapidly since 2005, and is expected to continue to rise quite quickly, until 2040 or so. There are approximately 25,000 more people over the age of 65 every year, of whom approximately 5,000 will be over the age of 85.

This poses two challenges – first how do we pay for healthcare for the larger number of elderly people, and second how do we deliver it efficiently and fairly. (It’s worth pointing out that the panic about herds of older people roaming the streets in the future, demanding healthcare and pensions, is overstated. Most healthcare costs are incurred in the year or two before death anyway, and the usual measures of dependency ignore the quite large economic contributions of those over 65).

A rapid increase in the numbers of older people does pose a challenge – specifically the challenge of dealing with more cases of chronic disease, and more people with more than one chronic disease – people affected by ‘multimorbidity’. Unless this is met, and reasonably resourced, there will be severe problems.

The question

The question posed by the speakers last night was, fundamentally, can the Irish health service cope with these demands by business as usual, and the answer was an unequivocal no.

Too much care for people with chronic disease takes place in acute hospitals, or in private clinics, and that care is fragmented. Irish hospitals are at, or very very close to, capacity, with bed occupancy of 98% – far higher than they should be. They reviewed evidence showing that integrated care, led by GPs, can give a better quality of care, and can reduce the use of expensive health care, including hospital admissions, specialized investigations, and outpatient visits. For a small group of complex patients, a small group who account for upwards of half of total health expenditure, costs can be reduced by 10% to 20%.

The answer

They proposed a model of greater investment in general practice, with more care moving to the community, and much better access to hospital services, and special investigations, for GPs. This pattern of care would, very likely, improve patients’ experience of health care, improve the health of the population, and reduce costs.

Part of this would be a better GP contract. The current GMS contract forbids chronic disease management, and indeed 25 years ago, inspectors would go out to practices to make sure that GP’s were not managing high blood pressure in their GMS patients. However, a model where chronic disease care comes in piece by piece, over many years, will not work either. GP’s already know how to do chronic care, they just need to be resourced for it.

The politicians

The politicians sort of got it. Their biggest weakness was the failure to separate out general practice and primary care services. In Ireland primary care means HSE provided primary care, delivered by state employees. GP’s are private contractors. Their biggest threat was their universal view that the health care budget could not and would not rise much over the next few years.

Leo Varadkar, our current Minister for Health, said that health care had to focus away from hospitals and towards general practice. He would ring-fence cash every year to support the development of GP services and primary care. He spoke about the need for GP’s to lead in community care. He hoped that the large cuts experienced by general practice would be reversed from 2017, and that some allowances could be restored before then. He also indicated that expanded roles for pharmacists, community nurse, and others were on the way.

The Sinn Fein speaker, whose name I missed (apologies), urged free access to primary care, an increase in training places for general practice, and the introduction of some salaried GP posts.

Deputy Róisín Shortall spoke for the Social Democrats. She acknowledged that integrated care was vital, and that they aim for a single tier health system with much greater capacity in primary care and more innovation in care. She also felt that there would be little more money for health.

The FF spokesman, Senator Thomas Byrne had two good ideas, first that health care planning needed to run over many years; second, that the primary care budget should rise by €160m a year each year; and one very bad idea, that while they were happy to see free GP care extended, this should be on the basis of need, and not based on such factors as age. I advise them to read the Keane report, from September 2014 carefully, where the impossibility of this is carefully explained.

The FG spokesman, Senator Colm Burke, said that they would need to resource GP care properly, but felt that change would be hard, and that the health budget would not increase much over the next while. He also talked about primary care.

Conclusion

The solutions proposed by the GP’s and the IMO are straightforward enough. They can be delivered, and will, almost certainly, save money.

One big threat is the lack of capacity for change within HSE and the Department of Health. Although working models of community diabetes care have been evaluated in Ireland, and running for over 20 years, there is still no serious plan to implement and resource this most basic level of care, for one of the commonest chronic diseases, across the whole country. (There is a plan, but not a credible plan.) At the current rate of progress, chronic disease care in Ireland might be up to scratch in forty or fifty years. This is not acceptable.

The other threat is the lack of money. Overall, the Irish health care spend is quite reasonable. We spend a little below the OECD average per head, based on our GDP. Based on our GNP, which is a better measure for Ireland, we spend quite a bit above the OECD average. There are problems with these figures, but the overall conclusion stands. The problem is that we seem to get poor value for money, both from the public sector, and, especially, from the private hospital sector. To change how we deliver care, to move to a more efficient service, we will need to invest more, and quickly, in general practice. This will need an increased health care budget, rising by 6% to 8% a year.

If both of these cannot be delivered, then the most likely outcome is that the health service will continue to get worse, queues will continue to get longer, and preventable ill-health from chronic disease will continue to rise.

HSE Service plan 2016

HSE’s 2016 Service plan has just been published. I was on RTE’s Drivetime talking to Mary Wilson about it on Thursday night. It’s a long document, at 178 pages, with more detail and more useful information than previous plans. If you work in health, it’s worth looking at the pieces directly relevant to yourself and your patients.

The high level message is an 0.8% increase on the (expected) 2015 spend, or 6.7% on the 2015 budget. The good part is that talk from DPER about bringing the 2015 deficit forward into 2016, which would have led to a 5% cut in expenditure, has gone away. The bad news is that HSE probably needs a minimum of €300 million extra (that is above the 2015 spend, not the 2015 budget) in 2016, just to stand still, and it’s not getting it. The 2015 service plan took a similar approach to the budget, and 2015 was definitely easier than 2014. The acute hospital sector may have the greatest difficulty with a budget €83m less than they have spent in 2015. There is a lot of language about ‘significant financial challenges’ and ‘financial risk’, which is likely to be prophetic.

None of this was unexpected. HSE had suggested an extra €2 billion in budget, or about €1.4 billion in health service spend this year, which was never going to happen. The Irish budget is still very constrained by our commitments to the EU. These commitments may, or may not, be sensible (see a report from Brookings), but Ireland can do little to change them unilaterally.
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High salaries and public trust

The size of the salaries of senior trade union officials has hit the news in Ireland recently. As I write this, Eddie Downey, former president of the IFA, and a decent and honest man, is on the radio explaining the severance package of the IFA’s general secretary. At the same time as the IFA, and its members, face big challenges like climate change, falling commodity prices, and plans to increase dairy production, the organisation is consumed with a row about salaries. It appears that Eddie Downey was getting about €147,000 + benefits, and the secretary-general about €450,000. These salaries were not widely known to the members of the organisation, and when these became public knowledge there was an enormous row.

At the same time the secretary-general of the INMO,  Liam Doran, a notably effective trade union official, is refusing to comment on his salary. As his members move towards strike action next week, the media are looking to see how much he is paid. He’s not telling. He should!
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Ageing and Ireland

I was asked to speak earlier this year at a seminar on ‘Co-op Care – Co-operatives and elder care in Ireland’, organised by the Society for Co-operative Studies in Ireland. I’ve now had the opportunity to put these materials up,   together with the original presentation.

There has been  lot of concern about the impact on Ireland of our ageing population. Some concern is warranted – there will be more older people in Ireland than there are now, both in absolute numbers, and as a proportion of the whole population. This fact needs to be accommodated in planning and budgeting for both the short, and the long, term.

There is good evidence that this shift in demography can be easily accommodated in Ireland – primarily because our EU peers are well ahead of us in having ageing populations, and they seem to be doing just fine. This didn’t happen by accident, but by detailed, careful, planning and working with older people to ensure that their needs were met, and their choices accommodated.

Demographics

The number of older people in Ireland is rising, and rising fairly fast. This is for a really good reason – life expectancy is rising steadily, and continues to rise.

VSA30

The implication is that the proportion of older people will rise too. However this also depends on the number of births. Ireland has and maintains a relatively high birthrate. There is a measure – the ‘Old Age Dependency Ratio’, which reflects the number of older people per working age person in the economy. To be exact, it is the number of people aged 65 and over, divided by the number of people aged 15 to 64 (and multiplied by a hundred). The next graph shows this for a set of OECD member states.

OADR
Ireland has one of the lowest OADR in the whole EU, and while it is rising, it is nowhere near that in most of our peers. The number of older people is rising, but there are many more younger people, partly as a result of immigration, and partly as a result of historically high fertility rates. The OADR will rise, and will rise quite quickly in Ireland. The CSO predict that it will be about 30 by 2031, and about 40 by 2046. This will be a real challenge to us, but nothing that most of the rest of the EU has not already faced.

Health, and death

It’s a commonplace phrase that 70 is the new 50, but it conceals a real truth. Although people are living longer, they are also staying healthy for longer. In the 1920’s a man of sixty-five was old, and was likely to be frail. This is no longer true. The inelegant phrase used to describe this is ‘compression of morbidity’. Most people are reasonably well until the last year or two of their lives, and this has not changed, although the last year may occur now in their eighties, and not their sixties.

The main users of health care and social care are older people shortly before they die, and a group of people, across a wide span of ages, who are affected by more than one long-term illness – which is referred to as ‘multimorbidity’. The implication is that this is the group for whom our health services needs to work best. There is reasonable evidence that a combination of well-organised primary care, active intervention to maintain health, mobility, and maximal independence, and support for self-care, can improve the quality of life for this group of people, and reduce health care costs.

Responses

There are two responses to the issues described here. The first is to seek to induce panic – essentially arguing that this cannot be afforded, and that social and health care need to sharply pruned if the economy is to survive. This is not true – a detailed analysis is given by Bloom et al, in the Lancet paper listed below.

The more constructive response is to decide to cope with the issue. This is eminently feasible, and many other wealthy economies have already done this. The idea is simple enough, although the implementation is not! There are three objectives:-

  • Prevent morbidity
  • Defer disability
  • Support independence

These can all be achieved by restructuring, funding and incentivizing our health and social care systems to do so. There is good evidence for many effective actions to reduce long term ill health, starting before conception, and running up to the age of 80 or more. There are interventions for all ages, men and women, including lifestyle changes, environmental changes, health care, social support, community development and more. These are all feasible, but many fall outside the current scope of our health services – however, this can be changed.

For older people, services need to be made more client centred. Services must identify and meet the needs, of their clients, not the needs of the delivery organizations. Indeed this would be good advice for most health and social services! Most older people want to live in their own homes, or at least in the same area. This means that support to help older people needs to be  community based. I would argue that their aim ought to be to help people to live as independently as possible, in the location of their choice. Certainly we ought not to drive people into long-term care settings.

All of this is feasible, and affordable, but as I said earlier, it will not happen by accident – as the saying goes ‘Plan, or plan to fail’. Our older people deserve better.

Selected resources

There are a series of Lancet papers, published in February 2015, on ageing and health – all are worth reading.

  1. Suzman R, Beard JR, Boerma T, Chatterji S. Health in an ageing world–what do we know? Lancet. 2015 Feb 7;385(9967):484–6.
  2. Mathers CD, Stevens GA, Boerma T, White RA, Tobias MI. Causes of international increases in older age life expectancy. The Lancet. 2015 Feb 13;385(9967):540–8.
  3. Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O’Donnell M, Sullivan R, et al. The burden of disease in older people and implications for health policy and practice. The Lancet. 2015 Feb 13;385(9967):549–62.
  4. Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. Health, functioning, and disability in older adults—present status and future implications. The Lancet. 2015 Feb 13;385(9967):563–75.
  5. Banerjee S. Multimorbidity—older adults need health care that can count past one. The Lancet. 2015 Feb 20;385(9968):587–9.
  6. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. The Lancet. 2015 Feb 20;385(9968):640–8.
  7. Bloom DE, Chatterji S, Kowal P, Lloyd-Sherlock P, McKee M, Rechel B, et al. Macroeconomic implications of population ageing and selected policy responses. The Lancet. 2015 Feb 20;385(9968):649–57.

Three papers on compression of morbidity :-

  1. Forma L, Rissanen P, Aaltonen M, Raitanen J, Jylhä M. Age and closeness of death as determinants of health and social care utilization: a case-control study. The European Journal of Public Health. 2009 Jun 1;19(3):313–8.
  2. Payne G, Laporte A, Deber R, Coyte PC. Counting Backward to Health Care’s Future: Using Time-to-Death Modeling to Identify Changes in End-of-Life Morbidity and the Impact of Aging on Health Care Expenditures. Milbank Q. 2007 Jun;85(2):213–57.
  3. Fries JF, Bruce B, Chakravarty E, Fries JF, Bruce B, Chakravarty E. Compression of Morbidity 1980-2011: A Focused Review of Paradigms and Progress. Journal of Aging Research. 2011 Aug 23;2011, 2011:e261702.
Materials from a seminar where I first presented these ideas :-

Co-op Care seminar programme April 2015

Seminar presentation

Governing quangos – not so Wild West anymore?

Ireland has several hundred agencies set up by Government departments to do various things. These range from the slightly inscrutable, for example the ‘Bookmakers Appeal Committee’, to whom your appeals on losing a bet should definitely not be directed, to the instantly recognizable, such as RTE or the National Museum. These bodies, sometimes dismissively known as quangos, make up a sizeable part of the Irish State, as of other modern states. They spend a lot of money, most of which comes from taxpayers and the public, and provide many services.

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Merger of WIT and IT Carlow – risks and hard questions

In an opinion piece published in the Irish Times yesterday I responded to a report from Michael Kelly on the ‘Engagement and Consultation Process on a Technological University for the South-East‘. Today I’m going to expand on my earlier piece, and explore some of the other issues involved in setting up a Technological University in the South-East. I’m indebted to a number of people, from Waterford, Carlow, and further afield,  who contacted me about this over the last few days.

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MacGill Summer School

I’m just back from Glenties, in Donegal. I spent a few days at the MacGill Summer School. The School is an annual event, and has been running since 1981. If you wish, you can watch every session on the Donegal County Council website here. I saw most of the sessions form the Wednesday evening to the last session on Friday. MacGill drew a certain amount of criticism this year. One letter in the Examiner described it “nothing more than a ‘talking shop’ or junket for ‘has beens’ or ‘wannabes’. It offers nothing constructive to help solve problems of this country.” In a piece in the business section of the Irish Times Caroline Madden suggests that for the cynical it might be “a talking shop where navel-gazing represents the chief activity”. I don’t altogether agree.

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