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.”

John Nelder has died

Prof. John Nelder, one of the more remarkable British statisticians, has died, at the age of 85.

I never had the good fortune to meet him, but his work had a great influence on me. McCullagh and Nelder, Generalized Linear Models, was my first technical statistics book, as an epidemiology PhD student, and I used Genstat, which he originated, throughout my PhD. His clear explanations have stayed with me, and I am proud to recycle them to my own students (with attribution!). Genstat also showed me a way past the more ‘black box’ approach of SPSS and SAS, to the interactive data analysis, exemplified by R. I’d like to thank him, and offer my condolences to his family.

Impact of health expenditure on health outcomes in Ireland

    There have been major improvement in the health of the Irish population over the last 20 years, (e.g. McDaid, 2009 p228), with a rise in life expectancy overall of 5 years from 1990 to 2006. The rate of increase seems to have risen in about 1999, and while Irish life expectancy is still a little low by EU standards, there has been substantial improvement, especially for men. The health care system has many weaknesses, notably very poorly developed primary care, giving us, for example, strikingly low immunization rates (McDaid, 2009, p156). However public health care expenditure has risen substantially as the economy grew from 1995 onwards, form about €3 billion to about €15 billion in 2009. Overall health care expenditure has risen from 8.8% of GNP in 1995 to approximately 10.7% in 2007. What has been the impact of this substantial change, and how much of the improved health outcomes are attributable to the increased expenditure?

    The existing evidence strongly suggests that :-

    1. Mortality has fallen sharply over the last thirty years
    2. Healthcare expenditure has made a modest contribution to this, substantially less than one third of the total, and possibly only a few percentage points.
    3. Development of primary care, and the more effective delivery of prevention measures will likely lead to the greatest declines in mortality.

    Continue reading

Foul-up in cancer services – so what else is new?

Confusion reigns in the Irish health services. The Minister has been asked to resign, because of a very serious foul-up in breast cancer care in the Midlands, but has declined. The Taoiseach (prime minister if you only speak English) has promised her his full support, which is normally a prelude to walking the plank. The opposition (full disclosure – I support them) are rubbing their hands with glee. The night is hideous with the sound of chickens coming home to roost.

So, what happened?

Well, like most stories it depends when you start. If you start recently, it seems that a substantial number of women who had mammography (breast x-rays) , and a rather larger number who had ultrasound breast examinations, in Portlaoise hospital, have needed to have them re-done, and at least 6 of these women have breast cancer. At least 80 require a full re-assessment. Three consultants spent all day (Saturday 23rd) today in Portlaoise running an emergency surgical clinic to look after he first batch of these women.

Going back a bit, queries were raised about one radiologist in the hospital, and her work, both in mammography, and ultrasound, is being re-investigated. There seem to be two investigations going on, and I’m not clear how, or indeed if, they relate. I may not be alone in this, as the minister found out about the second investigation while attending an Oireachtas (parliament) committee meeting three days ago.

Going back quite a bit, the Midland Heath Board, which no longer exists, rejected a proposal to establish one cancer centre in their area about six years ago, and instead decided that it would be nice to have three. While it might have been nice, it was also completely impossible, but that didn’t stop them. With a lethal combination of chutzpah and ignorance they set up three inadequate centres.

What role this played in the later disaster is not yet clear. It may be that some poor sod is genuinely culpable, but it seems more likely that this represents another system failure.