In the light of recent discussion on the Child and Family Relationships Bill, and some of the issues raised in the forthcoming referendum on marriage equality, I have been looking at recent evidence on the outcomes for children raised by same-sex parents. In this post I will look specifically at the evidence relating to adoption. In a future post I will look at the wider evidence. First, what are my qualifications to do this? I’m not a lawyer, nor a social worker, nor a specialist researcher on this topic. What I am is an epidemiologist, with my original training in paediatrics, and a track record in child health research. I have a lot of experience in study design, and data analysis, and the critical reading of scientific literature. My cv is elsewhere on this website. I am not a lawyer, and will not be commenting on any legal issues in the bill.

The most accessible recent review on the overall topic of children raised by same-sex families, a report for the Williams Institute at UCLA, by Abbie Goldberg and colleagues, can be found here.

Background

There is a detailed explanation of the origins of the bill, with links to the relevant documents on the Children’s Rights Alliance website. I recommend particularly Geoffrey Shannon’s review, which is accessible from that page, or directly here. The CRA summary of the bill is concise, and I fully agree with it –

The Children and Family Relationships Bill represents the most important reform of child and family law for a generation. The proposed legislation seeks to put children at the heart of family law, provide legal clarity around various family types and address discrimination faced by children in non-marital families. It is hoped that it will significantly reduce the number of cases going to court due to the current legal vacuum.

There are a number of areas of the bill that are potentially controversial, although the most complex piece, on surrogacy has been passed back to the Department of Health for further review. As far as I can see from listening to discussions in the media over the last few days, and in particular to the contributions from Mothers and Fathers Matter, one issue is allowing adoption by same sex couples.

In the interests of full disclosure, I should add that I strongly agree that children have a right to identity, and specifically, to know the full details of their biological and social origins. I also feel, very strongly, that children whose parents split up, have a right to maintain contact with both parents. As a result, I strongly support the donor register in the bill, and I oppose anonymous sperm donation, ovum donation, and surrogacy. I respect the views of the people in ‘Mothers and Fathers Matter’, and I am friendly with one of the people involved, my ex-colleague from UCD, Ray Kinsella. I respectfully disagree with them on the issues of marriage equality, and the use of assisted reproduction technologies, and adoption, by same-sex couples.

Evidence

The summary of the evidence can be quite bald. There is no particular evidence that the outcomes of children adopted by same sex couples differ materially from those of children adopted by heterosexual couples.

There does not seem to be a huge amount of recent research on this topic. There is a paper by paper, and study by study summary elsewhere on this site, listing all the papers I have found, so if I’m missing something, please accept my apologies and let me know.

US First child adoption study

This is a series of papers on a set of couples adopting a first child from Abbie Goldberg, JuliAnna Smith and colleagues. These studies recruited a group of parents adopting their first child through adoption agencies, and gay and lesbian NGO’s across the US. To be included in the study, couples had to be adopting their first child, the child had to be under the age of 18 months, and both partners had to be first-time parents. Adoption agencies in the United States were asked to provide study information to clients who had not yet adopted. Both heterosexual and same-sex couples were targeted through adoption agencies to facilitate similarity on geographical location and income.

Couples were interviewed on two occasions, just after completion of their assessment of suitability for adoption (the home study), and three to four months after the placement began. They were asked to complete questionnaires after each of the interviews, and again 12 months after the placement. There were between 120 and 140 couples in the different reports from this study, a little over a third of whom were heterosexual couples, about a third, female same-sex couples, and a little under a third male same-sex couples.

There were no material differences in outcomes for the children, and the experiences of the parents were also very similar between the three groups of families, and were as expected from the existing literature on adoption.

The Los Angeles study

There are two reports from a study of children adopted by 82 families in Los Angeles (60 heterosexual, 15 gay, and 7 lesbian) from Justin Lavner, Jill Waterman and Letitia Peplau, who took part in the UCLA TIES for Adoption service. This was, and is, an add-on service, to routine pre-adoption support, for people adopting ‘high risk’ children from foster care. The parents in this study were recruited between 1996 and 2001. Families were assessed at 2 months, 12 months and 24 months after the placement.

Children showed improvements in behaviour and intellectual ability after adoption. There was no difference between the three groups of families in these outcomes, although the children adopted by the same-sex couples had slightly higher levels of biological and environmental risks prior to adoptive placement.

The high risk adoption study

This was a study of parents, fostering children, with a view to adopting them, through US Child Welfare Systems. 84 people took part, from 42 couples, (17 lesbian, 13 gay, 12 heterosexual), who were interviewed 3–4 months after they were placed with a child whom they intended to adopt. This was a qualitative study.

It is well known that the challenge of fostering a child, with a view to adoption, is considerably greater than that of the more common adoptions. Again, there were few differences between the three sets of couples. All identified issues with the legal system, with social services, and with the child’s relationship with their birth family. For the same-sex couple and added stress was the variable legal recognition for them both as adoptive parents. In some US states only one member of a same-sex couple can legally adopt a child. A second stress was anxiety about the views of the birth parents about a placement with a same-sex couple. Neither of these was raised as an issue by the heterosexual couples.

Interpretation

There is not a huge amount of evidence on the question we are addressing here, outcomes for children adopted by same-sex couples. However, the evidence is very consistent, and is also consistent with the wider body of evidence on adoption. There is no evidence for worse outcomes in children adopted by same-sex couples. It is of course, almost an academic joke, that every paper ends with a call for further research, and some further studies on the outcomes for all children raised by same-sex couples have started recently. As far as I know, there are no new studies specifically looking at the outcomes of children adopted by same-sex couples underway. If you know of some, please let me know and I will edit accordingly.

Is there enough evidence for the Child and Family Relationships Bill to become an Act? Given what these papers show, it is hard to argue that further research is a high priority. There are many pressing social problems, few researchers, and limited budgets. However, for making policy, there is a moral and ethical imperative to make use of the existing evidence, whether it is abundant or scant. My own judgement, and it is a judgement, though I hope an informed judgement, is that there is enough evidence to support equality in adoption for same-sex, and heterosexual couples. I believe that the onus is on those who argue against allowing adoption by same-sex couples, to produce the evidence to support their case.

The IPU held a seminar today, reported by Paul Cullen in the Irish Times. I wasn’t at it, but I found the report intriguing.

Based on Paul’s report, and the press release on the IPU website, the general proposition was that ‘Pharmacists hold key to reducing pressure in GP’s surgeries’. There were two main points, one that many minor ailments which could be dealt with elsewhere are managed by GPs, and the other that more generic prescribing could save the Irish health system a lot of money. The second is true, but only if we get our act together on generic drug prices, and enforce generic prescribing, as the NHS has done. Incidentally, there is reasonable evidence that pharmacists can make an important contributor to improving the quality and safety of prescribing (e.g. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010 Oct;48(10):923–33). What about minor illness and pharmacists?

There is quite a bit of evidence that pharmacists can make a very useful contribution to healthcare. There are two relevant Cochrane reviews, one on the ‘Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns, and one on’Community pharmacy personnel interventions for smoking cessation‘. There are over fifty other reviews, and several hundred studies on various outcomes, diabetes, asthma, mental health, and more. Most of the ones I have skimmed seem to look at the role of pharmacists as part of a larger system of integrated care, or the impact of pharmacists on prescribing. Based on the reviews, and on reading the abstracts of about twenty interesting sounding papers, there is reasopnable evidence that pharmacists can provide effective care to patients.

The key intervention at the conference came from Colin Bradley, the professor of General Practice in UCC. Paul Cullen reports him as saying ‘there were significant financial and other obstacles to be overcome before GPs agreed to the scheme.Family doctors could feel it would “take bread out of their mouths” and needed to be properly resourced to treat chronic diseases’. I think he’s right. Why?

Suppose that it was decided to switch care to pharmacists in the morning. What would happen? Pharmacists are cheaper than GPs, partly because they can subsidize their premises by selling drugs, perfumes, makeup and so on. Pharmacists would skim off some of the simpler end of the GP business, leaving GPs to deal with the more complex cases, and the sicker patients. These are the patients GPs lose money on. In the same way that private hospitals in the US cherry picked the less sick patients to treat leaving public hospitals to deal with the more costly, and less profitable, cases (e.g. Cram P et al. Insurance status of patients admitted to specialty cardiac and competing general hospitals: are accusations of cherry picking justified? Med Care. 2008 May;46(5):467–75), pharmacists would undermine general practice. I also suspect that if anything went awry, the patient would end up back at the GP very quickly.

I’m not arguing that the IPU are wrong. From my perspective we seriously under-use pharmacists. We are beginning to use them more effectively, for example in giving flu shots, but there’s a long way to go. If we are to make full use of community pharmacists, practice nurses, and all the other staff in primary care, we need a new primary care contract, covering GPS, their staff, pharmacists, and others. We need a contract which pays, properly, for managing chronic disease, and which pays, properly, for integrated care.

This will cost. My (really crude) estimate is about one billion euros extra to fully develop primary care. This money could come, mostly, from the current acute hospitals budget, along with many skilled staff, patients, and clinical responsibility. In such a system, community pharmacists could use their full range of skills, not just improving prescribing, and reducing drug errors, but also providing direct patient care, mainly for those chronic disease managed by drugs, such as diabetes, raised cholesterol, asthma, and high blood pressure. This care would be provided as part of a team, in my view a team led by GPs, sharing information, sharing responsibility, and sharing the resources provided.

Could this be done? I think it could. Irish GPs are very innovative, and they continue to do an amazing amount of good care, in a very difficult situation. Irish pharmacists, evidently, want to step up, and meet this challenge too. Will the HSE/DoH join in? I really hope so!

I was lucky enough to be one of the judges at the BT Young Scientist’s exhibition in Dublin in the first week of January. This gave me two rather different opportunities to see Irish school children. First, I got to meet the people who put in projects. These included the eventual winners, Ian O’Sullivan and Eimear Murphy from Cork, and about forty other people, all aged between 12 and 18, whose group projects, all entered into the Social and Behavioural Sciences section of the exhibition, I got to judge. (Every single project gets judged three times, independently, and those in the running for prizes are reviewed by further judges.)

They were a very impressive group. Even the weakest projects showed effort, enthusiasm, and a lot of work. The good ones would have been very acceptable from good university undergraduates. The projects that won the prizes in our section, were better again. The overall winners, after only a years work, were at the standard I’d expect from a good MSc, and their work was immediately publishable. This is an astonishing accomplishment. All the students who entered, their teachers and their families, deserve great credit.

The topics they presented, however, show a slightly darker side to Irish life. ‘Alcohol consumption – does the apple fall far from the tree’ from the overall winners asked a simple question – How do parental attitudes to alcohol affect the behaviour and attitudes of their teenage children? As you might expect, they do, and the effect is strong. What is most scary from their work is the high prevalence of really risky drinking in both teenagers and parents, and the complete lack of understanding of the risks.

A team from Kinsale community school in Cork, looked at awareness of male suicide, and access to services and education about suicide. they found a good level of awareness, but quite big difference between young men and young women in how they respond to their distress. The boys, as has been shown before, tend to bottle it up.

Several groups looked at obesity, diet and exercise. A team from Loreto Abbey looked at how much people knew about the calorie content of common foods. A group from Ardscoil Ui Urmoltaigh, in Cork looked at easy ways to detect spiked drinks. A group from St. Colmcilles’ in Dublin looked at how much exercise was needed to use the calories in common snacks – far more than you might expect, by the way. A group from Mount Sackville in dublin looked at calorie labelling and its effect on vending machine sales. The group most affected was the small proportion of kids who got most of their lunch time food from the machines.

The most original title I saw was definitely ‘On Wednesday we wear pirate hats’ a piece of experimental sociology from Avondale in Wicklow. They established, as social norm in their school, that people wore black paper pirate hats on Wednesdays – a graphic example of the power of persuasion!

Overall, these young men and women showed a great awareness of the real challenges facing many of their peers. Those who go into the Young Scientist, besides being bright, tend to be confident and outgoing. They realized clearly that not everyone is like that. They see, day by day, the effect of inactivity, obesity, alcohol, drugs and poor mental health on the lives of their peers, and they document that effect beautifully. Most of those I met have a very sophisticated, what we might describe as ‘grown up’, understanding of their world, and of the people in it. They also have lots of good ideas on how to improve it.

The Irish government is also good at identifying risks. We have pretty good policies on obesity, exercise, alcohol use, and sexual activity. However, if doing anything to implement one of these policies causes any bother, we just fold over and lie down. There are still vending machines in most Irish secondary schools selling junk. We still have far too little PE on our schools, secondary and primary. Proposals to stop Diageo and friends peddling alcohol to teenagers with pictures of instantly recognizable GAA and rugby stars have run into the ground. An ex-president of the GAA described this, quite correctly, as ‘spineless’. One very prominent ex-rugby star, Brian O’Driscoll has even signed up as a Coca-Cola ambassador.
Our children deserve better. Frances Fitzgerald, the Minister for Justice, is bringing forward a new bill on children and family relationships, which I welcome. Could we add a bill to support our children in living healthy lives, even if it might hit the profits of multinationals, and the pockets of sports stars?

The HSE Service plan is out today, and you can read it here. I’ve just finished reviewing it for the Pat Kenny show on Newstalk.

Some key points

  • Some money to reduce waiting lists in acute hospitals
  • Some money to support moving patients out of hospitals in to home care or long term care
  • Hospital groups to happen
  • Palliative care service in the Midlands for the first time
  • Better access to diagnostics for GPs – ultrasound now, more services in 2016
  • Some increase in spending on disability services and mental health
  • 0.7% increase in spending from 2014 outcome
  • New use of balanced scorecard methods to hold managers to account
  • More investment in ICT

All in all the new service plan represents some progress, and a lot of stabilisation. Over the last few years HSE has made much more systematic use of information to monitor activity and track progress toward its objectives. This is elementary good business practise. They now publish monthly performance reports, which provide a great resource for seeing what HSE are up to, and what they had planned.

From my perspective, 2014 was a really hard year for everyone in the services. It started with what I believe were fantasy savings of €666 million, later reduced to a less obviously sarcastic €619 million. Over the year, many measures deteriorated. Trolley counts, which had fallen quite steadily since 2011, began to rise, waiting times for admission began to rise, and even the newly available waiting times for outpatients began to rise. The number of medically discharged patients, often cruelly and unfairly called ‘bedblockers’ rose – and is now nearly 800, the size of a very big teaching hospital.

There were some more positive signs. A pressure sore initiative reduced sores by 70% in the North-East, a great result. There were 13 people waiting over four weeks for urgent colonoscopy at the end of September, but all were seen by the end of October. In the past, these people would have been left waiting.

Looking at the service plan for 2015, it looks realistic. The savings figure, of €140 million will be tough, but can be reached. There is an acknowledgement that both waiting lists and people on trolleys will continue. Having spent several nights myself on trolley in A/E I do not take this lightly, but at least the problem is known, it is being measured, and they will try to manage it. There is more money for mental health and disability services – not enough more money, but perhaps enough to hold things stable, and make some people’s lives better in 2015. There is some extra money for home care packages, and some for nursing home packages (Fair deal), mostly aimed at frail elderly people, too many of whom are sitting in acute hospital beds.

There are some interesting straws in the wind – there is money for new services in general practise, with better access to diagnostics, a new service for managing people on warfarin, and a move to do more minor surgery in primary care. The Medicine’s Management Program are getting more resources, presumably to improve the quality and reduce the costs of prescribing. If this can be made to work, it could be a very big win. Ireland does very poorly on measures of prescribing cost, and generic prescribing, and we spend a lot of money on drugs. This could be the very modest start of a serious shift of resources into GPs and primary care. It’s not big enough, and not fast enough for my taste, but it looks realistic, and achievable.

This is a credible plan. If cost containment, especially in the acute sector, works, and this is a big if, it can be delivered, and will modestly improve the situation for quite a few people.

The next Seanad will be elected, most likely in June 2016, in the same unsatisfactory way as the current Seanad. Most of the senators will be elected by the votes of local authority members, and members of the Dail. The Taoiseach will appoint eleven senators. Six members will be elected, most likely as at present, three by graduates of TCD, and three by graduates of the NUI. There is a slim chance, if the bill on electoral reform is passed very quickly, that six candidates will be elected by graduates of all higher education institutions (HEIs) in the state. Unfortunately, given that the next election has to happen by the end of March 2016, at the latest, it looks as if even this modest reform may not happen in time.

What can we do to make the best of this bad lot? The only part of the Seanad that has any shred of democratic legitimacy are the two third level panels. This is far from perfect, with a very restricted franchise, but it is the best we are likely to have in time for the next election. It is also the only place where Irish citizens living outside Ireland can influence Irish elections, and it might form the seed for more effective Seanad reform after the next Oireachtas elections.

If this is to happen, I think we need to get as many people as possible voting, and that means encouraging people to register for their votes, and use them. The Seanad electoral register closes on February 26th, and will be used from June 2015. The only requirements are that you must be an Irish citizen, and you must have graduated from the NUI or TCD.

From today, November 2nd, there are 116 days to go. Please help me to get the word out. I’ve set up a Facebook page for this at http://www.facebook.com/HaveYourSayInIreland.

Trinity graduates

Full information about the Trinity Seanad election and the electoral register is here. Short version, you have to fill in this form, sign it, and post it to Student & Graduate Records, Academic Registry, University of Dublin, Trinity College, Dublin 2. It must be received by Thursday February 26th, 2015. You may not email it.

TCD degrees

Most eligible graduates attended Trinity, but there are also many DIT graduates who have TCD degrees. I’m not aware of any other such institutional links. Please let me know if I am missing any. Please note, you have to be an Irish citizen to vote, but you do not need to be Irish resident.

NUI graduates

Full information about the NUI Seanad election, and the electoral register is here. Short version, you have to fill in this form, sign it, and post it to National University of Ireland, Records Office, 49 Merrion Square, Dublin 2. It must be received by Thursday February 26th, 2015. You may not email it.

List of NUI colleges

The list of NUI colleges is longer than you might think. Besides the obvious, UCD/UCC/NUIG/NUIM, it includes RCSI, NCAD, the IPA, Milltown, and the Shannon College of Hotel Management. Some graduates of other institutions are also eligible, depending on exactly when you graduated – these include Mary I, St. Pat’s Drumcondra, NIHE Limerick (but not NIHE Dublin), Thomond College, and St. Angela’s. A full list is here. Please note, you have to be an Irish citizen to vote, but you do not need to be an Irish resident.

There is an admirably bonkers new paper from Peter Ainsworth of the IEA with the title “Universities challenged: funding higher education through a free-market ‘graduate tax’”. I’m obsessed, amongst other things, with ways of funding higher education, so I read it cover to cover.

Some background first, as many people will not be familiar with the IEA. They describe themselves as a think-tank whose members, “all those associated with the Institute support free markets – though with different “schools” of free market economics being represented”. Their official history begins with a quote from John Blundell, their former director-general thus “Hayek advises Fisher; Fisher recruits Harris; Harris meets Seldon. In nine words, that is the start of the IEA.” This gives a pretty good idea of their perspective on the world. It isn’t mine.

The report itself, a concise 52 pages, has a good deal of useful material. There is a very good summary of how the UK got to their current situation, where a student loan scheme, intended to reduce Government payments to Higher Education, is now likely to cost more than the direct grant system it replaced. There is a very lucid analysis of the different economic perspectives of students, higher education providers, and the state. There is also a good description of the various perverse incentives in the current system in the UK. There is nothing on the perverse incentives on other countries, for example the US. There is less on the perspective of the families of students, but this is, I think, a relatively minor omission. There is a good review of the graduate premium to earnings, with useful data showing how it has varied over time, and between disciplines. There is particular emphasis on the variation between individuals in this premium, and the consequent uncertainty about investing in Higher Education.

Ainsworth’s key idea is this ” Universities should individually or collectively offer contracts to their students, who would agree to pay to the university they attended a given percentage of their [future] earnings. That percentage could vary by course and institution, though some agreement between universities could be helpful to achieve standardisation. Essentially, the university would be taking an equity interest in the graduate premium earned by the student, although any student who chose to do so could, alternatively, pay the full fees up-front prior to beginning their studies.”

He suggests that, based on a few models around the world, this might be between 4% and 10% of their income over a certain level, for a number of years, and that these payments should receive tax relief. This would be a private contract, and, as such, universities could securitize the earnings.

What’s right with this idea?

  • It could do a good job of aligning the economic interests of students and universities. Presumably institutions whose graduates were of very poor quality, as perceived by employers, would do badly. There would certainly be a strong incentive for universities to give students access to skills and competences, rather than information. Some of these would be specifically vocational, and others more generic.
  • Higher education would be free at the point of use, at least in the sense that there would be no upfront fees. These are, to say the least, a disincentive to poorer students. Ainsworth suggests that the state might choose to provide maintenance grants to support some students at university.
  • It would do a very good job of sharing the risk in choosing to do higher education between the students and the university, with the university taking all the downside risk – i.e. the student never gets a high enough salary to start paying.

What’s wrong with it? Ainsworth does try to address several challenges, for example, there would be an obvious incentive for universities to concentrate on subjects with a high graduate premium – putting less vocational course at risk. Such courses could instead be state supported, as a matter of public policy.

I see some further serious objections, which are not fully considered.

  • Incentives to select students – there would be a huge incentive to the university to cherry pick students, and I foresee a large premium on very low risk people, for example white male students from UK ‘public’ schools (i.e. private schools in other countries). Students with disabilities would be a significant risk to the university.
  • Incentives to select the courses provided – many universities, including all those I’ve worked in, provide courses which are actually uneconomic, or at best very very marginal. We also do a lot of experimentation, running course for a few years to see if they meet a need. These courses, and the associated innovation, provide a wider range of choices for our students, and support a wider range of voices and perspectives within higher education. I doubt that targeted government subsidies would, or could continue to support these.
  • Cost – the cost of collecting these funds is not discussed, apart from a suggestion that universities might get together to do it, or set up a common organization to collect the money. This is not unreasonable, but I suspect the costs would eventually eat up a sizable fraction of the money collected, perhaps 20% or more. The cost of collection is a critical part of any higher education funding system.
  • Risk – bringing in such a scheme is fraught with risk. There would be very large uncertainties, which would put at very serious risk any but the most well endowed (i.e. highly capitalized) of higher education providers. The education system requires fairly stable funding, if it is desired to provide a stable education. A reasonable estimate is that is takes 5 to 6 years from the start of development, to the first graduation of student from a new 4 year degree program. It might be another decade before the graduate premium from such a program could even be estimated. It would be very hard to make a business case for such an investment. The transition costs of any major shift in education funding are large, and are not considered by Ainsworth.
  • Feasibility – Ainsworth argues, on the basis of a number of examples, that such a scheme is feasible. The examples he gives are for small scale, highly targeted schemes. I’ve reviewed each of them, as best I can, and I remain very dubious of the ability to scale such ventures. One important example, CareerConcept AG seems to have had no media activity since 2011, which is surprising. Lumni looks much more promising, but has still only covered 5,000 students in four countries since 2002.

In short, I think the IEA report well worth reading, but I do not think that the proposals in it are feasible, desirable, or affordable. The UK desperately needs a better system of funding Higher Education. This isn’t it.

I’m just back from the Patients First meeting in Navan. This is their third meeting, but the first I’ve been able to get to. Their core goals of the campaign are :-

  1. Budget must protect health service and patient care.
  2. An independent, transparent, free, easily accessible, feedback mechanism that provides all patients, carers and family members the opportunity to share their healthcare story and engage with service providers.
  3. Safe staffing based on patient dependency alone.
  4. Legislated requirements to publicly display daily staffing levels vis-à-vis patient dependency requirements.
  5. Legislated requirements to publicly consult and assess all cost improvement plans.
  6. National long term strategy for patient involvement and engagement across Ireland.

There was a respectable attendance, with about 40 people there, in the Newgrange hotel. The audience was a mixture, with several nurses from the area, including Navan hospital, and the local hospice team; a scattering of politicians (full list on their website) including TDs Helen McEntee and Regina Doherty; a couple of people with specific stories of bad outcomes; and several other local people. The speakers were my old friend Hilary Dunne of Patient Opinion Ireland and Karen Clarke from the INMO and Drogheda. David Hughes of the INMO chaired the evening.

The format was interesting. It started with a video from the BBC about the Francis inquiry into the Mid-Staffs trust disgrace. I re-read the executive summary over the weekend, to prepare for this evening. It still shocks and upsets me. I’ve been ill and helpless in hospital in Ireland, more than once, but I always got great care. I might not have been so lucky over there. If you haven’t read it, please do.

Then Hilary and Karen spoke briefly, presenting their personal perspectives on the issue. Stephen McMahon, and Steve Tweed, who were meant to speak as well, were caught in the tailback on the M50/M1 junction, and didn’t make it over. It was passed over to the floor then. There were three patient stories, one from the patient themselves, and two from relatives. Several other people, including the local councillors and TDs spoke as well.

What did I think? This was a genuinely useful meeting. The patient stories are a powerful narrative, and serve to focus attention on why we need to reform the service. The response of the politicians was very positive and constructive. The two TDs will be going back to Minister Varadkar, and one hopes that he will take their feedback seriously. There is the nucleus of a group here to lead the wider discussion on the structure and funding of the services, which I think is needed. The patient centred approach, and the explicit recognition of the importance of patient’s voices are a huge benefit to any further policy discussions.

A good evening, and congratulations to the organisers.

 

If you know me, you will know that I am not the most dexterous person. I was never going to have a career as a surgeon. I read a paper some years ago that gave me hope that I might yet improve (not that I might take up surgery). I vaguely recollected that the authors had shown evidence of unexpected brain plasticity in older people, by documenting structural changes in the brain after teaching people how to juggle.

I was talking to a colleague from our Business School the other day, who, it turns out, is interested in brain plasticity, and functional MRI studies as part of her work in the Business School in DCU. I mentioned this memory to her, and she was very interested, so I went off to find the paper.

I did a little digging in PubMed, and eventually found two papers dealing with the impact of learning to juggle in older people.

The first looked at the effect of age on the ability of people to learn to juggle.

Performance on a juggling task

Performance on a juggling task by age, at baseline, after instruction and after practise. (Source – redrawn from Voelcker-Rehage C, Willimczik K, Motor plasticity in a juggling task in older adults-a developmental study. Age Ageing. 2006 Jul;35(4):422-7.PubMed PMID: 16690635.)

This graph shows the main results. There were over 900 people, across a wide range of ages (6 to 89). Each person was scored on video, doing a juggling task, first without instruction – ‘Baseline’, then after verbal instruction ‘After Instruction’, and then after 7 sessions of practise -‘After Practise’. The key finding was that, while people aged 15 to 29 did better than anyone else on this learning task, there was little indication of any further decline in performance with age.

The second paper compared MRI scans over 6 months of 69 older people (mean age 60) who were taught how to juggle. The first scan was a baseline, the second after three months, with (more or less) regular practise, and the third after a further three months, with no structured practise offered. They found that a particular area of the brain, known as the human middle temporal/V5 complex, which apparently plays a central role in the perception of visual motion, increased in size by 3 months into the study, and shrank back again by six months. There other changes in brain structure as well. These were similar to the changes they had found in a group of 20 year olds, in an earlier paper.

What does all this mean? From my perspective the most interesting finding of neuro-scientists over the last 20 years is that the human brain changes over time. Work on brain development in late adolescence and early adult life, has shown that ‘adult’ brain structure is not reached until the mid twenties. This capacity for development continues throughout life. This ties in with the evidence that learning can slow the development of Alzheimer’s disease – literally use it or lose it..

The work on juggling shows that we retain, into old age, the capacity to learn, and that this capacity does not decline much, if at all, with age. We have the capacity to change our brains as well as our minds.

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There’s been a lot of discussion about public sector salaries over the last few days, and in particular about consultant salaries. A revised salary scale has been proposed for all newly appointed consultants, raising the starting and final salaries significantly. At the same time there are pre-budget murmurings about raising public sector salaries again. I am, of course, a public sector worker, so I am not entirely disinterested in this. My 2c are that if any public sector salaries are to rise, this rise should be confined to the lowest paid workers. People like me, on high salaries, ought not to be getting a sniff of a salary rise for several years to come.

Leaving that to one side, I want to look at the evidence on consultant salaries. I am a doctor, but I’m not a consultant. I’ve worked in hospitals for quite a few years, although not recently, and I spent a lot of time as a patient a few years back. I also work with quite a few consultants, and trainees (i.e. non-consultant hospital doctors) on various research projects.

The question being asked is simple enough. Are Irish consultants well paid, or poorly paid, by comparison with their peers? The context is two-fold; first, there is a really serious problem getting people to apply for and accept consultant posts in Irish hospitals; second, consultant salaries were cut quite sharply, like most other public sector salaries, between 2009 and 2013.

What is the evidence? The main source is the OECD Statistics database. The OECD collects a lot of information about various aspects of the health services in their member states, and they put a lot of effort into making these as comparable as possible. They collect information on the incomes of medical consultants (Health -> Health Care Resources -> Remuneration of health professionals). For Ireland, the OECD only collects information on the salary of consultants, not on their private earnings. These earnings are quite substantial, a point to which I will return. The OECD presents this information in a number of ways, each of which tells a slightly different story.

First a caveat, while the OECD does a lot of work to make these figures as reliable as possible, there are still big problems. All the data are averages, so you can’t compare pay-scales directly. The pension levy is not deducted from the Irish salaries, but it is definitely deducted from the take-home pay. The salaries exclude private practise income, which varies hugely. No data is collected on the up to 500 (or so) fully self-employed private consultants in Ireland. UK data may not properly account for merit awards. What is classified as a consultant in one place, is not necessarily a consultant elsewhere. In a word, these data are usable, but not necessarily always right.

I’ve done a series of graphs, each of which I will discuss separately. In each of these graphs each country has a different colour. Those self-employed( dots) and those on salaries (solid line) are drawn with different types of line. Ireland is always shown as a solid line with large dots added, and this line is labelled as well.

Specialist incomes as a proportion of the average wage

Specialist incomes as a proportio of avergae wages - Data from OECD

This graph shows, for a wide range of OECD countries, the incomes for salaried and self-employed consultants, as a proportion of the average wage, from 2000 to 2012. For Ireland in 2012, this figure was 3.65, so in that year an average Irish consultant earned, from their salary alone, more than 3 and a half times as much as an average Irish worker. Irish consultants are towards the top of the salary scale. Their actual salary fell sharply, but so did everyone else’s, so the proportion is pretty flat. The other thing to notice is that self-employed consultants make far more money than salaried consultants. There are issues with accounting fully and properly for their costs in running the practise, but the overall message is pretty clear. Note that there are no data on private income for Ireland.

Specialist incomes in US$ at purchasing power parity

Specialist incomes in US$ PPPData from OECD

A different way of looking at the same figures is given by using a common currency. In this case the OECD use what are called “US dollars at purchasing power parity”. The idea is that money, even in a common currency, is worth less where the cost of living is high. OECD calculates a rough equivalent, between countries, and over time, for the amount of money that will buy an equivalent lifestyle, allowing for these varying costs. The story this graph tells is very similar. Irish consultants do well, coming at the top of the salaries with their colleagues in Luxembourg. Self-employed consultants do better.

Specialist incomes in Euro

Specialist incomes in Europe - Data from OECD

US dollars at purchasing power parity are all very well, but not exactly familiar. Euros are probably more useful for most of us. This graph shows the data for the Eurozone countries only. The picture is very similar to the previous graph.

What does all this tell us?

Allowing for the limitations of the data, I do not think that one can argue that Irish consultants are underpaid. I do think that they deserve high salaries – being a consultant is a tough job, with long hours and heavy responsibilities. Part of the confusion is that the salaries of Irish consultants are being compared with the incomes of self-employed consultants in other countries. Their salaries are notably lower than the incomes of self-employed consultants in other countries, but this is what you would expect.

What isn’t known, as far as I know, is the total income of Irish consultants. It is known that the private insurance companies pay about €360 million annually to the consultants, but, again as far as I know, there is no information on their office fee income, nor on the other costs that have to be met from this income (e.g. rent, office staff and so on), nor on how these fees are distributed (there is enormous variation in the private practise incomes of Irish consultants). It would be useful to have these figures.

The figures we do have suggest a need to ask a very serious question. Given that the salary covers only a proportion of the income of our consultants, how much should they receive, in total, as a fair compensation for their difficult and challenging work? I don’t have an answer for this, but I think that there is a real need for a careful, objective discussion of the topic. Consultant salaries are a sizable proportion of our total health expenditure, and we have to make sure that we are getting value from this spend.

My other question was “why is it so hard to recruit people for consultant posts in Irish hospitals?” As far as I know, no-one really knows, although there is a study going on at the moment. Pending the results of this work, there may be some clues in the latest Medical Council report on the medical workforce. Striking features are high rates of withdrawal from the register for younger doctors, and a very high proportion of doctors (1 in 3) who qualified outside Ireland. None of this suggests a service that is very attractive to its own.

Talking to colleagues over the last few years, the impression I have is that many people are unhappy about coming to work in Ireland. Some points people have made to me :-

  • Almost all consultants work very hard, and work very long hours
  • Most work significantly more than their contracted hours in the public sector
  • Our health system is complicated, with poor communications, mostly by mail, fax and telephone
  • Hospital bed utilization is extraordinarily high by international standards
  • Primary care is critically underfunded, so a great deal of that work lands back into the hospitals
  • Information systems are weak, and many processes are done manually, that have been automated in other countries for many years

Nonetheless salary cuts matter – I was enlightened by a colleague who drew my attention to the final report of the Strategic review of medical training and career structure. One of their recommendations (page 81) is :-

“The Working Group recommends that the relevant parties commence, as a matter of urgency, a focused, timetabled IR engagement of short duration to address the barrier caused by the variation in rates of remuneration between new entrant Consultants and their established peers that have emerged since 2012.”

I gather this was based on strong representations from trainees who met with the group, who intimated that the salary differential (of 30% between new entrants and existing staff) was the main factor, though by no means the only factor in their decision making.

So salary cuts do matter. It is possible that the new salary scales will produce the desired flood of people applying for posts in our services. I certainly hope so. However, I remain of the view that we need to fix many other issues in our services as well, if we are to keep these people working here, and have a decent and affordable service.

Acknowledgments

Colleagues, who had better remain anonymous, unless they wish to comment below, have very helpfully critiqued my observations. I appreciate this. I have a better grasp of the limits of the OECD data, and have found work on the attitudes of senior trainees to the lowered salaries for new entrants – their views were very negative. I was wrong to argue that salary cuts were relatively unimportant – they were (and are) important, but still not the whole story.

Appendix – specialist incomes and GDP/GNP

The OECD presents the earning figures in one further way, by comparison with GDP per capita. This is a very rough guide to the wealth of a country. Because Ireland is the home to a large number of multi-national companies, with very large exports, Irish GDP is not regarded as the best guide to the size of the economy. GNP is preferred. The CSO publish GDP:GNP ratios annually, and the latest published is for 2012. The ratio has fallen from about 0.85 in 2004 to 0.81 in 2012. I’ve assumed that the figure for 2013 will be similar. I’ve calculated the salaries of consultants as a share of the per-capita GNP, and added this to the graph.

Specialist incomes as a proportion of per-capita GDP - Data from OECD - Data for Ireland as a proportion of GNP added using CSO figures.

This shows a similar story to the other graphs, with one interesting twist. What is very noticeable is that Ireland is now much further up the rankings, both for GDP, and especially for GNP. This says, that relative to the wealth of the country, our consultants are well-paid. Again this excludes their private incomes. The peak in 2009 reflects the collapse in GNP, and not a rise in consultant salaries.

Technical note

The graphs are done in R using Hadley Wickham’s elegant ggplot2.

Final decisions on the National Paediatric Hospital will be made shortly. One key element in the plan is colocation. What is it, and what are the implications of colocation for hospital site selection?

Colocation is the location on the same or adjacent sites of a children’s hospital, an adult hospital and a maternity hospital. There are several distinct types of colocation, with different objectives. To begin with I consider the likely effects of different types of colocation on patient care.

First, is colocation of paediatric services. The aim is to put all national tertiary paediatric services, and the secondary paediatric services for the Dublin region, on one site. At the moment these services are split across four sites, Crumlin, by far the largest site, Temple St, Tallaght, and Beaumont. There are several reasons why this is a good idea.

  • Managing the complex needs of very sick children demands close co-operation between many specialist doctors, nurses and other experts.
  • Requiring some staff to work across sites, imposes heavy travel time costs on them, and reduces the level of service they can provide.
  • There are significant economies of scale in providing access to costly technologies, for example MRI and PET scanners, the more complex laboratory facilities, and specialised theatre facilities.
  • Facilities with high throughput of patients are better for training more specialized clinical staff, and provide more opportunities for research.
  • Follow-up and rehabilitation care for recovering children often requires intermittent access to a wide range of specialists, which is easier to provide at a centre supporting a full range of services.
  • Provision of education and play for sick children, some of whom will spend many months, or even several years, on and off, in hospital.
  • Provision of both on-ward and off-ward accommodation for the parents of seriously ill children.

To achieve this any proposed site must have space for the full range of secondary and tertiary paediatric services. This is the case for most of the major international childrens’ hospitals.

Colocation of the children’s hospital and a major maternity hospital is also of great practical importance. The aim is to have immediate access to a full range of specialists, operating theatres and intensive care for the sickest newborn babies. This matters because, about one quarter of the children currently in the intensive care unit in Crumlin are newborn babies. Many of these high risk babies can now be identified before delivery. This allows the transfer of their mothers for delivery, which is much better for the baby than a long ride, late at night, in an ambulance. This colocation will support the future development of new specialised services, such as foetal surgery.

Colocation of an adult hospital and a maternity hospital has been less often discussed, but is also important. Every maternity hospital already has arrangements with local adult hospitals to support the care of pregnant women. Colocation makes these arrangements more substantial, and allows their wider development. A small number of pregnant women each year develop serious illnesses, beyond the capability of even a well-equipped maternity hospital. Equally, a small number of seriously ill women are also pregnant, and need the expert intervention of obstetricians and midwives to secure the best possible pregnancy outcomes. In both cases, this is best achieved by access to an onsite, or adjoining, adult hospital. The three big Dublin maternity hospitals are almost unique worldwide in not having such facilities.

Colocation of a childrens’ hospital and and adult hospital also has some clinical benefits. In the past, many of the more specialized paediatric services were provided by adult specialists who also did some paediatric work. This model of practice is passing, and almost all paediatric services are now provide by fully trained paediatric specialists. What is more relevant, is the transfer of care from paediatric services, to services for older adolescents and adults. This is facilitated by colocation, but only adolescents living in Dublin will benefit, as those living outside will have their care transferred to their local hospitals anyway.

Trilocation, that is the provision of maternity, paediatric, and acute adult hospital services on the same or adjacent sites is an ideal model. Most, but not all, of the large modern children’s hospitals that I have reviewed, are colocated with a maternity hospital, and a majority are colocated with an adult hospital. This model, if run well, provides the clinical benefits of the other types of colocation.

Besides the clinical benefits, better integration of management systems brings huge benefits. These include better efficiency, leading to lower costs, and better operational performance, leading to better outcomes. Many of these improvements do not require colocation, but all will be facilitated by it. These include common governance and audit systems, common infection control, common purchasing and personnel systems, common laboratory, imaging and IT facilities, more effective staff management, and better accountability for service delivery. Arguably, if colocation is to succeed, setting up this integration ought to precede the design and build of the new hospital buildings. Indeed, it would be fair to criticize the existing National Paediatric Hospital board, for their failure to begin doing this.

A further advantage of a single paediatric facility is in building up the scale and scope of both research, and training. The existing hospitals have modest, and moderately successful, research units. This division of a limited capacity across three sites seriously impedes Irish research into childhood disease. Horizon 2020, the next EU funding scheme for research has great opportunities for Ireland. Other countries have built major clinical and biological research centres, which are major employers. To do this, we would need a critical mass of researchers, doctors, nurses and patients. The NPH, on a single site, beside a research active adult hospital, would be a great start. Training is also inhibited by the the fragmented paediatric services. Ireland does not have the resources to provide advanced training in the care of sick children in three places. Again, a single hospital will greatly improve our capacity to offer advanced training to the next generation of doctors, nurses, and other child health professionals. Co-location with maternity and/or adult hospitals will provide further benefits in training and research.

Any proposed site for the new hospital needs to have the space to include all of these elements. A single acute inpatient facility for the children of Dublin, and a single tertiary centre for the children of Ireland, ought both to be non-negotiable. In my view, the next requirement is a colocated maternity hospital. Given the fiscal realities of Ireland today, this means one of the three Dublin maternity hospitals, based on its present site. It is nice to dream of shiny new maternity hospitals on green field sites, but its not going to happen. The very sickest babies in Ireland ought to be spared long ambulance transfers wherever possible. An acute adult hospital, either on site, or adjoining is also very desirable. Finally any site must have space for expansion. New buildings will be needed. Old buildings will need to be refurbished. Doing this essential work on a cramped site raises costs and increases the risks to children.

We can built a really good facility for Irish children, for Irish mothers and for Irish adolescents. We need less territoriality, less spin, and more focus on the actual needs of sick children and their families. We need the integration of management systems, and boards, to begin as soon as the constituent bits are identified. We need all of this in the next few weeks. Will we get it? Watch this space…

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