Claiming our Future

10 am We’re meeting up, a thousand people from all over Ireland in the RDS Industry Hall. This is a space more familiar to me from the Horse Shows of my youth. On my table, we have, among others, a union secretary (who was my contemporary in TCD back in the ’70s) , a Jesuit community activist, a worker for older people’s rights, a youth worker, and an artist. The Twitter link is #cof3010

10:30 We’ve started by doing a values exercise. We were asked to select five values from a list provided, and to suggest one more. We picked Care, Equality, Environmental sustainability, Solidarity and Accountability. We added ‘public conversation’ to the list. All of these will be added up across all the tables, and the final choices put up.

1:05 Key values identified from the voting system were :-

  • Equality
  • Environment
  • Accountability
  • Participation
  • Solidarity

12:15 Now we’re listening to Mary Coughlan, (not the Tanaiste, the singer) doing ‘My Land is too Green‘, and the ‘Magdalene Laundry‘. It’s going down very well. She’s a great performer.

12:30 The elephant in the room – what we all refuse to see. The alternatives that are possible. Myths that society must be run for the markets. What are the policy alternatives? Policy choices based on this document. Looking for policy option that can be implemented over 5 years, that might be transformative, and can be popularized.

12:40 Working on Section 2a Economy and Environment. Our priorities are :-

  1. Change the current development model and define and measure
    progress in a balanced way that stresses economic security and social
    and environmental sustainability.
  2. Regulate banking to change the culture from one of speculative banking
    to one where currently state-owned banks and new local banking models
    focus on guaranteeing credit to local enterprises and communities.

1pm Working on Section 2b Income, Wealth and Work. We need to look widely at models from other countries, e.g. Iceland, other Scandinavian countries, Wales, Scotland. How can we achieve better income equality? Property tax reliefs, pension tax relief, are all possible targets. Is equality or jobs the priority? Both are important. Equality could start at the next budget, and there is a lot of evidence that increasing equality increases many other desirable features of society. following discussion, our priorities were:-

  1. Prioritise high levels of decent employment with a stimulus package to
    maximize job creation in a green/social economy.
  2. Achieve greater income equality and reduce poverty through wage, tax
    and income policies that support maximum and minimum income

1:25 pm Lunch! Lots of choices outside in the grounds. A lovely day too.

2:30 Back from lunch – Votes from section 2a and 2b were
Economy and environment

  1. Change the current development model and define and measure
    progress in a balanced way that stresses economic security and social
    and environmental sustainability.
  2. Prioritise a legally binding national sustainable development strategy that
    caps resource use, reduces greenhouse gas emissions and implements
    measures to protect our life support systems.

Income, Wealth and Work

  1. Achieve greater income equality and reduce poverty through wage, tax
    and income policies that support maximum and minimum income
  2. Prioritise high levels of decent employment with a stimulus package to
    maximize job creation in a green/social economy.

2:45 Working on Section 3a Governance – we felt that it was critical to “reform representative political institutions to enhance accountability, equality, capacity, and efficiency of national and local decision makers”. Without this little joy could be expected.

3:15 Section 3b Access to public services, and public sector renewal. We had a long discussion about importance, or otherwise, of fixing the public service – “Make efficiency, integration, and equality the goals of public service reform”. It was felt that specific service delivery policies should have priority. I’m not sure I agree.

4:10 Votes on Section 3a

  1. Reform representative political institutions to enhance accountability,
    equality, capacity, and efficiency of national and local decision makers.
  2. Develop participatory and deliberative forms of citizens’ engagement in
    public governance and enhance democratic participation by fostering the
    advocacy role of civil society organizations, civics and ethics education in
    all school levels and a diverse media.

4:10 Votes on Section 3b Access to Services and Public Sector Renewal
· Make efficiency, integration, and equality the goals of public service

  1. Provide universal access to quality healthcare, childcare and services for
    older people.
  2. Invest in equality in access to and participation in all levels of education
    (preschool to university).

3:30 Listening to a rap group – least said , soonest mended.

3:45 Feedback time – show of colored cards – green red and yellow. Do you want to work together? Result – a forest of green cards!

3:50 Ideas for action

  • Sustainable Ireland, following the natural steps program from Sweden
  • Singing revolution, use music to sing the protest, record and spread it widely.
  • Charter for Ireland, on the liens of Charter 77
  • Progressive think tank
  • Virtual network of people and resources

4:20 Shaz Oye singing for us. Great voice, solo singer, gospel style, also sings with guitar. Very lively, very strong voice, very moving. Finished with ‘Talking about a Revolution‘, which can come off a sad cliche, but worked well with her voice.

4:30 Wrap up – Set of values chosen. Policy options identified. Infrastructure set up, on-line local, regional and national. Actions will continue. Each of us has written a postcard, addressed to us, with a stated action to be done over the next month. These will be posted out to us in a month. Build ‘Claiming our future’ independent and self-reliant. Make today a turning point for Ireland.

4:45 – Gloria sing for us. A great way to wrap up the day.

5:00 We all go home.

Futures of Nursing

The US NAP have just published a report on the ‘Future of Nursing’. I’ve only skimmed it, but I’m impressed enough that I’ve ordered a copy. The US are facing exactly the same types of problem that we face, albeit in an even more dysfunctional system.
The authors note the accumulating evidence that nurses have a vital role in delivering care which is of high quality, accessible, and provides value for money.

They have 4 key messages :-

  1. Nurses should practice to the full extent of their education and training.
  2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
  4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.

We need to pay attention. The whole report is available from the link above, (registration is required), and ought to be compulsory reading for us all.

The real price of US healthcare

There’s a new paper published at Health Affairs which gives the final lie to the general thrust of Irish Government health policy. The heart of the actual policy is the maximization of private health care. The huge expansion of private health care, largely funded by tax breaks, has succeeded. We now have a big private sector, which, according to the CEO of the VHI, “has excess capacity [which] it will take a few years to be utilised. We do not need any more new hospitals. I don’t think we can fund it. I can’t see the business rationale for me as procurer of services to add to that capacity. It doesn’t make sense for us and we are entitled as a procurer who we contract with. Our view is that there needs to be a two- to three-year moratorium on expansion or new facilities.” (Sunday Tribune September 5th).

One might fairly object that this is not stated policy. Stated policy is [still!] the 2001 ‘Quality and Fairness, a health system for you’. However, this is not being implemented, or at least, not so as you would notice, so I prefer to stick with what actually gets done.

So, what are the likely consequences of these policies? Well, the problems of private health care are quite well understood. There’s fair evidence, from other countries, of failures in cost-control, shifting of risks, and costs, to the public sector, and fragmentation of care. The basic inequities in our system are well established. These policies will likely make the problems worse.

There;s new data from the US, published on the 7th. which is very relevant to this discussion. Muenig and Glied examine US 15 year survival data for middle-aged and older people, to answer the question “Is the US health system at least partly to blame for this deterioration in international rankings for life expectancy and medical costs? Or can the declines be better explained by statistical, demographic, behavioral, and social factors?” The short answer, is yes, for the longer answer read the paper.

HSE needs a programme of rapid, focused cost savings

Brian Kenny kindly invited me to give a talk to the IHCA AGM in Adare, Co. Limerick. I spoke about running the health services through a recession. I also wrote a piece which appeared in the Irish Times, on the same day, Saturday 2nd October. My original slides are here as a 6MB OpenOffice Impress file, and, if you insist, here, as a 6 MB Powerpoint file and here as an 9 MB Adobe pdf.

HSE needs a programme of rapid, focused cost savings

“IRELAND IS experiencing its worst economic crisis since the Great Depression of the 1930s. What are the implications for the public health service of the recent budget cuts and the likely ones to come?

The HSE has had rising budgets since 1995. This rise has partly gone to higher salaries, and partly to playing catch-up from the severe under-investment before then. The HSE will lose about €600 million this year, and is likely to lose as much again, or more, in 2011 and again in 2012.

These cuts are hitting frontline services quite disproportionately, for several reasons. First, many services are delivered by temporary staff, or low-paid staff on short-term contracts. Examples include home helps, some hospital nurses, some social workers, and others. Second, many frontline staff grades are young, and so have higher staff turnover for social reasons. Again, this affects key staff like nurses, community welfare officers, psychologists and social workers. Finally, some frontline services have been, effectively, discontinued, non-emergency dental services being an example. Given another two years of this, our health services will be badly damaged. What can we do to avoid this?

The various problems of the HSE have been thoroughly discussed in the media. It is well known that we have unaccountable services of variable quality. We have a two-tier health service with a vicious bias against poorer people. Our GP services are laughably underdeveloped. We have a large, unplanned, and unsustainable private health sector, which is destabilising the public services and the insurers. Services for adult and child mental health are a national scandal. Services for disability and long-term care are equally poorly developed. Ours is neither a quality nor a fair health service.

There are glimmers of hope. The concentration of cancer services in eight centres has worked well. Drug costs are falling, a little. New clinical pathways are being developed in the acute hospital sector. The quality of HSE management has improved.

There are less cheery signs. The primary care strategy is, more or less, dead. The HSE still has 11 financial systems, which are not mutually compatible. There is still intense confusion of roles and lines of responsibility within the HSE. The co-location of private hospitals consumes scarce HSE management resources.

So, what can be done now to avoid serious harm to patients over the next two or three years? In my view, the HSE needs a better financial structure and a rapid programme of focused cost savings.

The HSE’s financial system was described by the Minister for Health’s expert group on resource allocation as “fail[ing] to meet most of the guiding principles that [we] would consider essential to have a system that is fit for purpose”. There are now two detailed reports on this, one from my colleagues and me and one from the resource allocation group chaired by Frances Ruane. These reports agree in detail and complement each other. We need action on these, not further prevarication.

There are some obvious areas where a lot of money can be saved quickly – drugs, acute hospitals and private healthcare. For drugs significant savings have already been made and more are possible. Examples include the use of restricted drug lists; requiring high levels of generic prescribing; payment for the care of long-term illnesses (eg diabetes) based on following standard protocols of care; setting restrictive budgets for very costly new drugs; and requiring proof of cost-effectiveness for these drugs before they will be reimbursed. All of this could save as much as one-fifth of the total public drugs bill, about €240 million.

Improving acute hospital efficiency is certainly possible. A study of the economies, and the diseconomies, of scale in our system, should guide future decisions on hospital size and location. Measuring the efficiency of hospitals against their peers would be a powerful motivation for change. Requiring hospitals, as well as other service providers, to make more use of shared purchasing and shared services could save a lot of money. Setting up a unified management and budget structure within each of the eight new hospital networks would be a major step forward. I do not know how much this might save.

A decision to stop subsidising private healthcare would save a lot of money. Private healthcare in Ireland receives very large annual subsidies. These include €260 million in tax relief on insurance premiums; €90 million for the National Treatment Purchase Fund; €50 million to €100 million in the subsidy for private patients in public hospitals; and millions more in payments from insurers that never get collected. The tax relief on new buildings costs tens of millions a year at least; the costs of the co-location project are unknown, but might be as much as another €30 million a year. At least €20 million is the cost of training for staff from public institutions. Personal indemnity insurance for private practice by consultants and the two private maternity hospitals is an unknown cost but might be another €20 million annually. The opportunity cost of having consultants working off site is not known, but is probably high. This all costs at least €500 million a year and perhaps as much as €700 million.

A final source of income for the HSE is consultants’ fees. Private health insurance premium income is probably €1.4 billion this year. At least €350 million is paid to people who also hold public contracts. This could be levied directly by their employers, say at a rate of 50 per cent per year, bringing in a very useful €175 million a year.

These are drastic actions, but we live in very hard times. These measures would not be enough to avoid all the problems, but they would be a start. If the State does not do something radical, all health service users will suffer. These are, largely, the elderly, the disabled, the poor and the sick. While services will (still) be inadequate, at least they will be evenly inadequate. Is there any other hope?

Yes there is. It lies in the people who work in our truly awful healthcare system; the people who make it work, day in, day out, despite the problems; the people who do their best for their patients morning, noon and night. The film-maker Alan Gilsenan, writing in this paper on Tuesday, said of a nursing home in central Dublin, “Real care does not reside in the building or its facilities, but rather in the spirit of the people within.” The same is true of the HSE.”

Using R in research education

I’m at the UserR! 2010 conference at NIST in Gaithersburg, Maryland. This is the main annual event for R users. there have been whole series of presentations on using R in education. The full program lists the Pedagogic talks (3 sessions, and 9 talks, on the first day).
What I’ve seen so far is great work on training people in data analysis, in statistics and (to some extent) in probability, The work is really good, and I have lots of new ideas. What’s been lacking, and what I need to think about more, is the other part. There are at least three other elements,

  1. asking intelligent questions, that is questions that are well enough specified to be answered, and well enough considered to actually matter.
  2. using research information, and clinical information, to support good clinical decisions
  3. data cleaning, data exploration,

Any thoughts?