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.

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!

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.


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.


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.

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.


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

Portaloise – the HIQA report

Mother and Child - Photo by Aaron Kraus CC BY-NC-SA 2.0

Mother and Child – Photo by Aaron Kraus (CC BY-NC-SA 2.0)

The widely leaked HIQA report into Portaloise Hospital is out now. The various pieces can be downloaded from

The context is well known, serious failing in maternity care in Portlaoise, identified by a great team of reporters from the RTE programme PrimeTime investigates, and detailed in a very clear, and very explicit,  report from Tony Holohan, the CMO.

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DOCTRID conference – selected notes

I’m just back from the fourth DOCTRID conference  in Belfast. DOCTRID is the research arm of the Daughters of Charity. It funds and oversees research in the field of ID and autism by bringing experts from medicine, social science, education, computer science and engineering together. DOCTRID was established in 2010 as an international, interdisciplinary coalition of universities, service providers dedicated to improving the quality of life for people with Intellectual Disabilities (ID) and autism through research and technology.

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Primary care and the new GP contract

The new GP contract  was the subject of much debate and discussion at the IMO AGM over the weekend, and the members have supported it. There are more details of the draft contract on the IMO website, but all seem to be in the members-only section. (As I’m a member I can read them, but I don’t think it appropriate to share more widely). The council of the other main GP representative body, the  NAGP, met on Sunday, and are reported as having rejected it unanimously. What is going on?

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Adoption and same-sex couples – some evidence

In the light of recent discussion on the Child and Family Relationships Bill, and some issues raised by the referendum on marriage equality, I have looked at recent evidence on the outcomes for children adopted by same-sex parents. The short version is that there is no evidence for worse outcomes in children adopted by same-sex couples. My 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 to produce the evidence to support their case. In a future post I will look at the wider evidence on children raised by same-sex couples.

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HSE Service Plan 2015

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

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