Manifesto review 1 – health and Renua Ireland

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!

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