Trolley numbers in Ireland

One of the regular features of the Irish healthcare system is a series of ‘Trolley numbers’ – this refers to numbers of patients who have been assessed as requiring admission, but who are waiting for a hospital bed. Some wait on chairs, some on trolleys scattered around our Emergency Departments (ED’s) and some in extra beds or trolleys on hospital wards.

This matters for a number of reasons.

First, there are significant patient safety, and dignity, issues – it is impossible to provide adequate monitoring for an ill patients sitting in an ED corridor, perhaps tucked in behind another patient, perhaps in a side room. It is also very hard to provide patients in this situation with privacy, not to mention food, access to toilet facilities and washing. Speaking from personal experience of spending time on a trolley in a busy ED, it is very hard to rest, impossible to sleep, and generally a miserably uncomfortable way to pass a day, or two, or three.

Second it causes blocks further back the chain. At worst patients may be left sitting in ambulances in the ED car park. This removes an ambulance and crew from service, which is itself dangerous, and puts the lives of others at risk too.

Finally it makes it very hard to work in ED, especially for nurses, and the patient care staff, such as catering staff, nurses aides, and porters. All do their best, often going well beyond their usual jobs to help patients, but it is far harder than it ought to be.

This is, of course, a scandal. It would not be unreasonable for a few patients to be on trolleys, for a day or so, if there were some major incident, but this is now a regular feature of Irish hospital life. In most hospitals in Ireland, there are always a few patients on trolleys, and there are often twenty or thirty patients. This is not on, but it is now part of the normal operation of the Irish hospital system.

As can be imagined, this attracts huge public attention. We have just had a new record, of 612 patients on trolleys, and the media have focussed on the topic. The Minister, Simon Harris, a Fine Gael TD from Wicklow, has been quizzed about this, and about his response. To summarize, he blames a serious influenza outbreak, and a lack of preparedness in hospitals, despite an extra €40m in extra winter funds given this winter.

There is some truth in both explanations, although I notice that there were 600 patients on trolleys this time last year, with a very mild flu season. I am also aware of the huge effort that the acute hospitals have put into reducing trolley numbers. Irish hospitals have a broad range of in-hospital responses, including medical admission units, seven day discharge ward rounds, senior medical staff in ED, active bed management, and community liaison. They could do more, but honestly it isn’t working, and if I’m right, it won’t work.

I think that what we are trying to do, is a bit like treating a patient who presents with a pain in their left elbow for a sprain, when their real problem is a heart attack. Unless we can assess the cause of the trolley waits, we are not going to be able to fix them.

The main public response from my colleagues both in hospitals, and in general practice goes like this. OECD data show that Ireland has 2.4 acute hospital beds per 1,000 population, amongst the lowest in the OECD. The average is about 4.3. If we could increase our hospital beds to the OECD average, all would be well. I respectfully disagree.

oecd-2014bar

A more considered analysis goes like this.

OECD countries have very different health care systems, and very different histories. Ireland is one of a group of countries, including the UK, Spain and Sweden with relatively few acute hospital beds. Belgium, Germany, Austria and Lithuania top the EU table with three times as many beds as we have. This, in itself, is not a good measure of health system performance. Ireland has got one of the most expensive health care systems in the EU, but it would be hard to argue that it is one of the best. What really distinguishes us from our peers is the very low investment in primary care.

I believe that we do not use our hospital beds effectively. We certainly use them a lot, with bed occupancy rates well over 95% for most hospitals, which is far too high. There are plans, for at least the last 10 years, to do a bed capacity review, and Minister Harris now tells us that this will be done by the first quarter of 2017. This ought to provide a clearer answer to the question – how many beds do we need, and how should they be divided, between, say , ICU beds, HDU beds, emergency beds, elective beds, and so on.

As it is at any given time we have the equivalent of one of our large teaching hospitals, in beds, full of patients awaiting discharge to community support, but that support is not there. We have grossly excessive waiting times for appointments, and for outpatient investigations. Capacity for doing such work outside acute hospitals is almost non-existent, unless the patient has health insurance.

In other countries there is a more strategic approach. This starts with an analysis of costs. Most health care spending is used by a small number of patients. These are, largely, patients with multiple illnesses, and often, other non-health problems. There is now good data, form several countries, showing that active case management and integrated care for this group of patients reduces costs, and improves the quality of their lives. To do this, resources are provided in the community to do the case management, and to work with the patients to keep them healthy.

This requires integrated care between hospital and primary care, and between health and social care services. Ireland, unlike many other countries, has health and social care provided by the same organizations, but we derive no benefit from this, because we do not provide for integration between them. There is, of course, good practice on the ground, but this has never been scaled up and rolled out across the system.

A key element if we are to do this is to properly fund primary care. Irish GP’s have their own crisis coming down the line, with an ageing workforce, limited investment in services, premises, and staff, and a 40 year old contract which was out of date when it started, and now represents a major obstacle to progress. The Department is finally negotiating a new contract, and there is some hope that whatever emerges will be fit for purpose. There isn’t a lot of time to get it right though.

What might a new system look like? My own idea is a service centred on patients and their needs, in which, for most people, most care will, as at present, be delivered in the community, at home, or in their local practice. Practices will be better staffed, and offer a wider range of services to their patients. To make all this work we need integrated care – this is sharing of care, information, and resources between the patient, and all those involved in their care, GP, hospital clinic, social care, and others.

For most patients this poses few challenges. However, there is an important subgroup of patient, a group of people with more complex health care needs, and often more complex social care needs, who need more. For this group, who are less than 5% of the population, but who are responsible for more than half of all health care expenditures, there is now good evidence from studies in many countries, that effective integrated care can cut costs, reduce hospital admissions, and improve their quality of life.

To make this possible, we will need skills and investment. We will need to draw on good ideas from within Irish health care, and further afield, but given that, we can train people and develop the skills to make this happen. To pay for this we will need to shift resources from acute hospital care to community care and general practice. This will require significant extra investment to cover the costs on both sides as we make these changes. In 2017 Primary care is due to get an extra €30 million from the HSE service plan. This isn’t nearly enough. It’s hard to estimate what is needed, but a rough figure would be about €600 million a year extra in primary care. This would be reached over a few years, and would be counterbalanced, to an extent, by smaller increases in hospital care costs, as services and staff were transferred across.

More fundamentally we need a direction of travel. One of the reasons why the Irish services are so expensive and work so poorly is that there is no agreed vision for the future of Irish health care. Most of those involved are fighting their own corners. This is quite understandable, but it’s not getting us anywhere. There is an Oireachtas committee on the future of healthcare, whose report has been postponed until April. If the Irish state, and the Irish health services can get behind a credible vision for the future, and work towards it over 5 to 10 years, then there is some hope that we could end up with a sustainable health service. If we don’t know where we are going, we’ll get nowhere. This is the real challenge for Minister Harris, and for Ireland.

Futures for post-school education to STEM or not to STEM

This is based on a presentation I made to the Future of Work conference, November 29th, in  Santry..

The problem

Ireland has a problem in education, which restricts our economy, and imposes heavy costs on us all. There is a large group of people who are disengaged from work, and who will need help, including educational help, to reconnect. Many of these are in two groups, unemployed young people with limited skills, and older people in long-term unemployment.

  • Ireland has had, for many years, a high proportion of our young people who are Neither in Education, Employment, nor Training – so-called NEET’s. Of our 15 to 29 year old’s 17% now fall into this group. There is considerable inequity, with much higher risks for those living in poor areas, and among those from poorer families. During of the recession the size of this group rose steeply, and thankfully it has now fallen, but it is still much higher than the EU average.

 

  • There are roughly 90,000 people aged 25 to 54, in long-term unemployment, 2 in every 3 of whom are men. The number of young people (20 to 24) affected has fallen steadily, due both to emigration, and to job creation, but there are stubbornly high rates of long-term unemployment in those older than 25.

This costs all of us. There are the obvious costs, easy to calculate, such as loss of income, and economic output, and social welfare costs. The less obvious costs are higher, with high risks of ill-health, poor mental health, and death, the loss of a sense of value, and heavy costs to the families of those affected, especially as unemployment drags on.

The response

One response to this is education. We have a complicated further education (FE), and higher education (HE) system. Much of it is full time courses for school leavers. These have a role, both as an opportunity for development, and in providing socialisation, foundation knowledge, and relevant skills, for their future careers.

There are also many more flexible courses, often part-time, designed for those who choose it, or who have commitments which make full-time study impossible. These courses are more flexible, and can adapt to the student, or to the local economy. Life-long learning is part of the system, although Irish data show that most of this is done by younger people, with third level qualifications.

Another response is helping people get back to work. There are many ‘labour market activation programs’. Some of these work, and some likely don’t, but there have been benefits. The education sector has also contributed, with an expansion of apprenticeships, and better access to many courses. Overall Ireland has a well educated workforce, and this is a key part of our international competitiveness.

Future skills

No-one knows what skills and education people will need in the future. To quote an employer interviewed for the National Skills Strategy ‘The skill of learning to learn; employers across the globe cannot predict the skills they will need for jobs that do not yet exist, but those who have proven to be adaptable, curious and know their own learning style have succeeded in rapidly changing industries’. There is much written about changes in employment, education, and training, often as if these were new, and unheard of, happenings.

The truth, of course, is that Ireland has had continual changes in work, lived with global competition, and often had high levels of political uncertainty, since at least 1800. One difference now, and a very welcome difference, is that whose who lose out, have votes. There were huge job losses, and minimal investment, in very specific parts of the US and the UK, over the last forty years. All of these areas have recently voted for Mr. Trump and Brexit, respectively. The Irish equivalent, both rural, and urban, seems to have led to a less dramatic political change. There is a political, an economic, and a moral mandate to address the needs of those who lose out.

STEM

A key part of the official and media rhetoric in response to these problems has been to promote Science, Technology, Engineering and Mathematics (STEM) subjects, as the solution. Almost all the examples, although not all the actions, given in the recent National Skills Strategy have to do with STEM. There is extensive media coverage of STEM deficiencies, and proposals for improving STEM teaching at every level of Irish education. Most of the new money expected in education in 2017 is related to STEM.

I acknowledge that the post-school education sector has changed, and is notably more flexible, more accessible, and more responsive than a decade ago. Looking at some of the key problems which remain, I don’t believe that a focus on STEM alone is enough. FE and HE are still designed for school leavers and full-time students. Students with limited academic skills are still not well catered for. Our system remains too restrictive.

I believe that we need to move further, to a more flexible student centred system, more closely tied to its local economy. I fear that we don’t produce graduates with the flexibility and imagination to cope with the ‘wicked problems’ that face us all. These are things like global warming, mass migration, cultural inclusiveness, or controlling corporations, which don’t possess a simple, manageable answer. They are the true grand challenges of our times. These aren’t STEM problems, but political, social, or philosophical problems.

STEM plus

Of course we still need STEM skills, but I argue for ‘STEM plus’. Everyone won’t do, nor wish to do a STEM subject. We need a balance of skills, training, and education, covering STEM topics, but also topics like critical thinking, philosophy, social science, languages, art and more. We must support flexibility and creativity, from pre-school to retirement and beyond.

How can this be done? There’s certainly no quick fix. I believe that if we put students at the centre our post-school education system; if we choose to provide opportunities for education by many routes, to support both better access, and different learning styles; if we provide accessible eduction to a very high standard; if we work more closely to serve, and develop local communities, and local businesses; if we decide to ‘think globally and act locally’; then I think Ireland could make very useful progress over the next five years.

Still no resolution on James’ site for NPH

I’ve been reading the submission from Connolly for Kids to the Oireachtas Health Committee. The submission is here, and the covering letter is here. My own views on the location of the NPH have changed little over the last few years. I wrote about Colocation, colocation, colocation in 2012, and I think the analysis there is still sound. For me, (a former paediatrics trainee, before going to public health), the most important feature is a maternity hospital adjoining the children’s hospital. Adjoining means accessible by corridor without going outside. Colocation with an adult hospital is not useless, but is much less useful than the Department of Health have suggested.

Given this perspective, I always thought the Mater site was complete non-starter. It was never going to be possible to fit the maternity service, nor a reasonably sized children’s hospital onto that site. After this decision was reversed on planning grounds, there was a challenging site selection process. I was involved, working on the proposal to locate the NPH beside the Coombe hospital, however, in the end the St James’ site was chosen. This was a much better choice than the Mater. It is a bigger site, more open, with better public transport, and a bit less traffic.

Unfortunately, as time has gone by, the weaknesses of that site are becoming more obvious. There is no immediate plan to bring in a maternity service, and it looks as if the NPH will, quite effectively, prevent any future major site developments for the adult hospital. St James’ is one of the biggest, and most important acute hospitals in the country, but large parts of it need to be rebuilt to meet modern service needs. Losing this opportunity would be a very high price for the NPH.

The other big issue is parking. Acute paediatric hospitals require much more parking that adult hospitals of the same size, because most of their patients arrive by car. This will not change. There is no prospect of parents of sick children bringing them in on the Luas, not by rail to Heuston station. It is already hard to park on the James’ site, and indeed the NPH build has already significantly reduced the number of parking spaces there.

It is true that Connolly does not have anything like the range of specialist services on the St James’ site, but this is not of great practical importance. The old model, under which some very hard-working adult specialists also did a bit of paediatric work on the side, is gone – almost all care is provided by fully trained paediatric specialists. Connolly could very rapidly be developed to meet a wider range of clinical needs, and this is probably necessary whether or not the NPH goes there. For example, if we ever do decide to build a national trauma centre, Connolly would be a far better choice than either James’ or Beaumont.

All in all, I agree with Connolly for Kids that Connolly would be a better site than James’ and would provide for a better and more affordable NPH. I hope the Oireachtas Health Committee will consider reviewing this decision.

PSEU questions for Seanad candidates

The PSEU have asked three questions of each Seanad candidate.

It was a good opportunity to think carefully about my own values and priorities. My background is that I am a medical doctor, trained in child heath, and a public health specialist. I am a political and a social activist. My key values are equity, social justice and transparency. I have worked for many years with communities affected by environmental problems, and with people with autism or intellectual disability. I am a member of FG, but, if elected, I will be an independent, and will not take the party whip,

1) What will you do to restore the cuts to Public Servants’ pay?

Public sector workers salaries (including mine) were sharply reduced as a result of our economic collapse. While the reported recent growth rates may well not be sustained, there is little doubt that our economy is improving. I feel that Ireland could and should begin to restore these cuts. For me, the priority ought to be restoring cuts to those in lower salaries first, as this will have the greatest economic impact for any given investment.

2) What are your priorities for investment in public services?

In order these are :-

Housing. Ireland has a crisis of homelessness. The health, social, educational and economic consequences of this are very well known, and we cannot afford them. We need a rapid program of social housung cobstruction.

Education. We spend too little on education, especially in deprived and marginalised communities. This has life long bad effects. Education is our best investment in the future. We need a focused strategy of investment, and reform, in education all the way from pre-school, to third level or apprenticeship.

Health. We have a very costly health service (public and private). Our health service is not what it could be, nor is it very responsive. I think we need to reorient our services in three ways. First to a patient centred service; second to a GP/primary care focused service; third to an integrated care service for people with chronic disease. This change will require investment, but it will be worth it if we do it right.

Older people. The number of older people in Ireland will rise rapidly over the next decade. This is, of course, cause for celebration. At the same time, it is a challenge which we need to meet. Our goal should be healthy, active and productive aging. There is a lot of knowledge and good practice in Ireland. This needs to be spread and implemented better.

3) Why should members of the PSEU vote for you?

I will be an effective and accessible voice in the Seanad if elected. I know how the Irish political system, civil service and HSE work, and how to work with them. I also understand how to work with community groups.

I feel that Ireland should have more universally accessible services, including education, health care, and social care. These will need to be paid for if that is what we want. I have a record of working and achieving change, both in higher education and in health care. I will bring this experience to the Seanad.

I am a life-long trade union member, and have served as a branch official, and an executive member, at various times. I was one of the leaders of the 1987 doctors strike in Ireland. I strongly support union rights, including a right, where necessary, to industrial action. I know a fair bit about industrial relations, and the importance of maintaining good communication between management and staff.

 

 

 

Remembering all the dead of 1916

The photograph below may baffle at first, because it is both familiar and unfamiliar. It is, of course, the First Dáil, meeting in the Mansion House in 1919, but it is not the usual photograph, reproduced many times since, it is one belonging to my late grandmother, Julia. Many of the faces will be familiar, deValera, sitting in centre of the front row, Arthur Griffith beside him, and many others. The man standing behind Dev, to the right as you look at it, in a natty coat with a velvet collar will not be so familiar, but it is my grandfather, Michael Staines.

FirstDail_shrunk

Here’s another photograph of him, from a few years earlier.

 

MS

 

The uniform may look strange too, I believe it to be his Irish volunteers uniform. We don’t know when this was taken, but it may well have been only a few weeks before the rising of Easter 1916.

It’s now the vigil of Easter Sunday and in a few hours I will stand outside the GPO to commemorate his actions and those of the other, but of course the word matters – the other what? Heroes, terrorists, freedom-fighters, murderers, patriots, an endless spiral of antonyms, which may say more about the writers than the reality. The rising happened and I think it changed the path of our history both for good and for ill.

In 1916 my grandfather fought in the GPO. Among other actions he brought weapons, cut the telegraph lines, shot at people, raised a flag, and eventually carried the wounded James Conolly out. Three of his brothers fought with him. A fourth died fighting in the Royal Navy later in World War 1. In 2016, in a world he would hardly have recognized, I will stand and watch a parade go by. In many ways he contributed to the world I live in, as a fighter both in the War of Independence and the Civil War (Free State), as a TD, as the founder of the guards, as an alderman, and as a senator.

I think we need to remember what happened as truly as we can. When I went to Trinity in 1978, I found one item that intrigued me, tucked away on a wall insude the Nassau strret side of Trinity. It was a memorial plaque to a young man, a liitle older than I who had died there in 1916. Such plaques were and are common around Dublin. What made this one different was that this young man was a British soldier Pte. Arthur Smith a Hussar from Hexham. I felt then, and still feel that this was the right thing to do. Would my grandfather have approved? I have no idea, but he died sixty years ago.

There is an association, called the Relatives of 1916, who have taken umbrage at the proposal to list all of those who died in the Rising and afterwards in Glasnevin cemetery. Leaving aside the question of how this group can speak for all of us, without asking us first, I think they are wrong, just as the activists from Misneach who scribbled on John Redmond’s banner  in College Green were wrong.

No one owns the Easter rising. No one owns the dead. There were no first class and second class deaths in 1916, so let us remember them all equally.

Evictions in Tyrrelstown

Listening to Morning Ireland this morning, and reading Kitty Holland’s excellent article in the Irish Times made my blood boil. Briefly 60 or more families in Tyrrelstown are going to be legally evicted over the next four months by Goldman Sachs. The reason is that a Goldman Sachs linked investment fund, Beltany Property Finance, wishes to sell the houses. As many as 208 families in total may be evicted in this one estate. All of this is legal.

I’m no lawyer, but the relevant Act is the Residential Tenancies Act 2004. The relevant bit is Section 34 ‘Grounds for termination by landlord’. Under this landlords may terminate tenancies on several grounds. One, Ground 3 i the table in that section is this :-

‘The landlord intends, within 3 months after the termination of the tenancy under this section, to enter into an enforceable agreement for the transfer to another, for full consideration, of the whole of his or her interest in the dwelling or the property containing the dwelling’.

I assume this is the basis for the termination of tenancies here (but again, I am no lawyer, so if you know better, let me know).

There is little rental property available in Dublin. This morning on Daft.ie there were 2 properties to rent in Tyrrelstown,and only 400 properties anywhere in Dublin at under €1,500 a month. The odds are that most of these families will have to move, and many will not be able to find accommodation at a price they can pay. The effect of these lawful actions will be to render a large number of families homeless.

The scandal of homelessness in Dublin has been obvious for three years. The roots go back a lot longer, to the crash, to a poor quality, and corrupt, planning system, to greedy and feckless developers, to the decision of local authorities not to bother with social housing, and to our appallingly lax laws on tenancy rights.  The response from the Department of the Environment today, that the tenants should use the PRTB to delay eviction,  is best described as embarrassing. Clearly the civil service, Minister Kelly, and the Department will continue to sit on their hands, and close their eyes tightly. It is time to act.

Although we have yet to form a Government, the Oireahctas is still there. If our politicians could focus on something other than Irish Water, and various combinations of coalitions, they could pass a quick amendment to the Act, giving tenants the right to continue a tenancy even if a property is sold. This is already the norm in commercial property here, and it is usual in residential property lettings in most other developed countries. Anyone up for this? It would be a very constructive way to commemorate 1916.

 

Politics, politicians, and political activism

There was a fascinating interview on the Marian Finucane show on RTE radio yesterday, with Gino Kenny, the newly elected People before Profit TD. Mr. Kenny, an interesting and thoughtful man, was asked how he felt about being a politician. He was quite clear in his response, he was not a politician, he was a political activist, and in any event he would never be a ‘career politician’.

This made me think. I’m not, yet, an elected politician, although if my Seanad campaign succeeds, I hope to be. I usually describe myself as a doctor, an academic and an activist. Asked for more detail, I will say that I am both a political activist, as a Fine Gael supporter, and a trade union activist; and a social activist, as much of my research, and much of my work outside the academic world, is concerned with supporting people who are working to make their lives better.

Politicians are not especially trusted, although they may be more trusted than journalists, they are much less trusted than academics, or ‘people like me’. Perhaps this is what Deputy Kenny is getting at when he rejects the label of politician, but embraces that of political activist.

Why am I an activist? I grew up in a politically aware and active family, and I was educated by the Jesuits. In both settings, there was a strong emphasis on doing what you could for your community and for others. My mother, Nuala, was very active on our community council, and my late father, Michael, was active in Fine Gael, working with the late Mark Clinton in particular.

I went to school in a fee-paying school, Belvedere, which backed onto the Hardwicke St flats in the North inner-city. No-one in my school could fail to notice the poverty, and the lack of opportunity, for those who grew up around us. Many people from the school, and the wider Jesuit community, notably Fr. Peter McVerry, were, and are, very involved in community work.

I’m a doctor, and I chose a branch of my profession, public health, which is centrally concerned with issues like poverty, justice, housing, diet, exercise, disability, social inequality, environmental justice, and access to education and healthcare. For me, moving into electoral politics, is a very logical continuation of my own work.

Why am I not running as a Fine Gael candidate? I support quite a lot of what the outgoing Government did, in particular, the necessary, and brutal cuts in expenditure, while maintaining social welfare rates, and the tax rises and the pension levy. I think salary cuts to high earning public servants, like myself, could have, and should have, been deeper.

I opposed two of their policies strongly, both publicly and privately. The first was their failure to deal with the housing crisis. NAMA should have been required to build some social housing. Tenants should have been given a right of tenure, even if a property is sold. This should still be done.

The second was the rise in child poverty. I’m not stupid. I was well aware that large cuts in public spending would hurt poorer people, more than wealthier people. I did not, and do not, believe that Ireland had any choice. Having just read Kevin Cardiff’s book on the financial crisis I am more sure of that than before. However, I also believe that some more targeted measures, such as maintaining support for school assistants, breakfast clubs and the like, and some low-cost innovations, for example targeted support for childcare for those seeking to return to work, would have made a difference.

Why run as an Independent, and why not take a party whip? Simply, if I have the honour of being elected, in the TCD constituency, to the Seanad, I can be more effective as an independent. I can do a better job, both of representing Trinity, and of advocating for progressive change, outside a political party.

Refocusing healthcare resources – moving resources into primary care and general practice

I’m talking this morning at the National Health Summit in Dublin. I’m in a session on ‘fixing A/E services’ after Liam Doran from the INMO, talking about the ED crisis, and Mark Aiello from the NHS, talking about the role of pharmacists in A/E care.

The basic question I’m covering is this :-

Will Primary Care finally get the investment it needs to keep people out of hospital?

Every party has a piece on health in their manifestos. Many promise a lot of extra cash for the health services. I’m not sure this is either possible, or a good idea, and I doubt if the money is being spent in the right areas. We all know that he Irish health service has problems. Many of these have been widely reported in the media. Stories tend to focus on trolley counts, waiting lists, costs for drugs, excessive numbers of managers, and poor care. There is some coverage of rising levels of overweight and obesity, and our big problems with alcohol and drug use and abuse. There is much less coverage of some of the other causes of rising health care costs, notably new treatments for diseases, and the costs of care for people with chronic diseases, like diabetes, arthritis, chronic bronchitis, depression and heart failure.

The costs of the service itself are also a source of concern. The state spends about €13 billion, and the public spends about another €5.3 billion on health care costs, one way and another, each year. New figures from the CSO, which came out in December, show that we spend a higher proportion of our national income, 10.2% of GDP, and 12.4% of GNP (which is a better measure of the size of the Irish economy), than almost any other EU country. Over the last few years the proportion of care paid for ‘out of pocket’ has risen sharply, raising costs for individuals and families who need care. It would be very hard to argue that we get a correspondingly good health service for this very large investment. It will also be very hard to get additional money for it.

Why have we got the expensive service we have? Our services developed over a long period of time, and grew organically. After World War Two, when many EU countries restructured health services, we did not. The British got the NHS, we got little or nothing until the health act of 1970. This has left a system which is full of perverse incentives. We have, largely, free hospital care for outpatients, but quite expensive primary care.

Most health care, by far, is self-care, or care by family members. Most of the rest, the more visible piece, happens in general practice, where there are about 27 million visits a year. Unfortunately, the GP contract (the medical card) was designed to cover acute illness, and not the long-term care for people with chronic diseases. There is very good evidence that the long term relationship between the GP and their patient brings big benefits to the care of such chronic diseases, and especially to care for people with several such diseases. This group of patients is where most health care spending goes.

The problem in Ireland is resources. Irish general practice is seriously underfunded compared with similar countries. While GP’s have the ability to lead, coordinate and give care for people with long-term illness, They do not have the resources. There are too few GPs and not enough money, for GPs and their staff. GPs have also lost a lot of their state income n the last five years. Will resources be made available?

There’s an election on. I’ve gone over the manifestos of all the parties to find an answer to this question. There are a lot of common features in the manifestos. Most agree on two things :-

  1. The Irish health care system is unfair, and needs to move to universal care, equally accessible to all (except for Fianna Fáil).

  2. The system needs to focus more on primary care than at present.

There is also wide agreement on a number of more specific policies. Most parties intend to reduce or abolish prescription charges. This is good, because these charges discourage the use of essential medicines. Taxes on sugary drinks are popular, as are a range of public health measures, on alcohol, smoking, and promoting physical activity, especially in the young. Drug policy is more divisive, ranging from more Garda work to prevent the sale of drugs (FG) to a health based approach to drug policy (Green Party). However, every single party wants a wide range of public health policies and measures to tackle major health problems.

Free GP care is also popular, and most of the parties support the idea in some form. They are much hazier about what it means, how to do it, and how to pay for it.

What is missing? Several parties (FG, Sinn Féin, and People before Profit) want to abolish HSE. I understand why, but the price of abolition will be to halt change in healthcare for at least three years. The NHS -has suffered greatly from this over the years. Organization structure is secondary, what matters is changing what happens when the patient meets the clinician.

The parties, the media and the electorate remain obsessed with hospitals, and hospital beds. Hospitals do matter. In Ireland, I think the balance between care in hospitals, and care in general practice, is wrong. Too much is done in acute hospitals, and far too little in general practice. This is one part of the problem in the hospitals. We need some more investment in hospitals, but a lot more in general practice. GPs will benefit from more access to diagnostics, but there is almost no capacity to take on more work, be that free care for more people, or more care for chronic illness.

If action is not taken, as time goes by the services will be further and further stretched. The number of older people is rising steadily. While more are quite healthy, the need for healthcare will rise steadily over the next decade or so. Failure to meet this need, will cause much unnecessary suffering and death. We’ve tried building a hospital centred service, and it has not worked well. To meet rising demand I think we will need to move to community based services, and the heart of these is general practice.

What can be done? There are some very good models, backed by evidence, to support the further development of general practice. HSE are just beginning to move some chronic disease care ito GPs, starting with diabetes care, but more people will be needed to deal with this. More GPs are needed, both to increase capacity, and to cover for retirement, and more training places. Well trained nurses working with GPs, can provide good quality care. Bringing the clinical staff working for HSE in the community, public health nurses, physiotherapists, and others, much closer to the actual individual practices would be very desirable. The idea is achieve integrated care, led by general practice, but linking in to the hospitals, and the other community services.

This means moving resources from other parts of the service to general practice. Given the very high overall spend on health care here, I do not see that we can reasonably make a case for much more money. Between 1997 and 2008 the health care budget rocketed, but I do not believe that health care improved greatly. None of the political parties have acknowledged these problems in their manifesto, and several propose very large increases in health care budgets. Some increases will be needed, but we need more effective plans to ensure that the increased resources are not wasted.

My slides are here

Saving General Practice and Irish Healthcare

The IMO organized a meeting on Wednesday evening in Buswell’s Hotel in central Dublin, just across from the Dáil (the Irish parliament building) on the topic of ‘Solving the Chronic Disease Problem – through General Practice’. It was packed out, and there was a very good line up of speakers, starting with Leo Varadkar, who trained as a GP and is now the Minister for Health, and including three prominent GP’s Austin Byrne, William Behan, and Tadhg Crowley. We also had spokespeople from a selection of the political parties, Sinn Fein, the Social Democrats, Fianna Fail and Fine Gael there.

The problem

Ireland has a very young population by EU standards, with a low proportion of people aged over 65. However, that proportion has been growing rapidly since 2005, and is expected to continue to rise quite quickly, until 2040 or so. There are approximately 25,000 more people over the age of 65 every year, of whom approximately 5,000 will be over the age of 85.

This poses two challenges – first how do we pay for healthcare for the larger number of elderly people, and second how do we deliver it efficiently and fairly. (It’s worth pointing out that the panic about herds of older people roaming the streets in the future, demanding healthcare and pensions, is overstated. Most healthcare costs are incurred in the year or two before death anyway, and the usual measures of dependency ignore the quite large economic contributions of those over 65).

A rapid increase in the numbers of older people does pose a challenge – specifically the challenge of dealing with more cases of chronic disease, and more people with more than one chronic disease – people affected by ‘multimorbidity’. Unless this is met, and reasonably resourced, there will be severe problems.

The question

The question posed by the speakers last night was, fundamentally, can the Irish health service cope with these demands by business as usual, and the answer was an unequivocal no.

Too much care for people with chronic disease takes place in acute hospitals, or in private clinics, and that care is fragmented. Irish hospitals are at, or very very close to, capacity, with bed occupancy of 98% – far higher than they should be. They reviewed evidence showing that integrated care, led by GPs, can give a better quality of care, and can reduce the use of expensive health care, including hospital admissions, specialized investigations, and outpatient visits. For a small group of complex patients, a small group who account for upwards of half of total health expenditure, costs can be reduced by 10% to 20%.

The answer

They proposed a model of greater investment in general practice, with more care moving to the community, and much better access to hospital services, and special investigations, for GPs. This pattern of care would, very likely, improve patients’ experience of health care, improve the health of the population, and reduce costs.

Part of this would be a better GP contract. The current GMS contract forbids chronic disease management, and indeed 25 years ago, inspectors would go out to practices to make sure that GP’s were not managing high blood pressure in their GMS patients. However, a model where chronic disease care comes in piece by piece, over many years, will not work either. GP’s already know how to do chronic care, they just need to be resourced for it.

The politicians

The politicians sort of got it. Their biggest weakness was the failure to separate out general practice and primary care services. In Ireland primary care means HSE provided primary care, delivered by state employees. GP’s are private contractors. Their biggest threat was their universal view that the health care budget could not and would not rise much over the next few years.

Leo Varadkar, our current Minister for Health, said that health care had to focus away from hospitals and towards general practice. He would ring-fence cash every year to support the development of GP services and primary care. He spoke about the need for GP’s to lead in community care. He hoped that the large cuts experienced by general practice would be reversed from 2017, and that some allowances could be restored before then. He also indicated that expanded roles for pharmacists, community nurse, and others were on the way.

The Sinn Fein speaker, whose name I missed (apologies), urged free access to primary care, an increase in training places for general practice, and the introduction of some salaried GP posts.

Deputy Róisín Shortall spoke for the Social Democrats. She acknowledged that integrated care was vital, and that they aim for a single tier health system with much greater capacity in primary care and more innovation in care. She also felt that there would be little more money for health.

The FF spokesman, Senator Thomas Byrne had two good ideas, first that health care planning needed to run over many years; second, that the primary care budget should rise by €160m a year each year; and one very bad idea, that while they were happy to see free GP care extended, this should be on the basis of need, and not based on such factors as age. I advise them to read the Keane report, from September 2014 carefully, where the impossibility of this is carefully explained.

The FG spokesman, Senator Colm Burke, said that they would need to resource GP care properly, but felt that change would be hard, and that the health budget would not increase much over the next while. He also talked about primary care.

Conclusion

The solutions proposed by the GP’s and the IMO are straightforward enough. They can be delivered, and will, almost certainly, save money.

One big threat is the lack of capacity for change within HSE and the Department of Health. Although working models of community diabetes care have been evaluated in Ireland, and running for over 20 years, there is still no serious plan to implement and resource this most basic level of care, for one of the commonest chronic diseases, across the whole country. (There is a plan, but not a credible plan.) At the current rate of progress, chronic disease care in Ireland might be up to scratch in forty or fifty years. This is not acceptable.

The other threat is the lack of money. Overall, the Irish health care spend is quite reasonable. We spend a little below the OECD average per head, based on our GDP. Based on our GNP, which is a better measure for Ireland, we spend quite a bit above the OECD average. There are problems with these figures, but the overall conclusion stands. The problem is that we seem to get poor value for money, both from the public sector, and, especially, from the private hospital sector. To change how we deliver care, to move to a more efficient service, we will need to invest more, and quickly, in general practice. This will need an increased health care budget, rising by 6% to 8% a year.

If both of these cannot be delivered, then the most likely outcome is that the health service will continue to get worse, queues will continue to get longer, and preventable ill-health from chronic disease will continue to rise.

HSE Service plan 2016

HSE’s 2016 Service plan has just been published. I was on RTE’s Drivetime talking to Mary Wilson about it on Thursday night. It’s a long document, at 178 pages, with more detail and more useful information than previous plans. If you work in health, it’s worth looking at the pieces directly relevant to yourself and your patients.

The high level message is an 0.8% increase on the (expected) 2015 spend, or 6.7% on the 2015 budget. The good part is that talk from DPER about bringing the 2015 deficit forward into 2016, which would have led to a 5% cut in expenditure, has gone away. The bad news is that HSE probably needs a minimum of €300 million extra (that is above the 2015 spend, not the 2015 budget) in 2016, just to stand still, and it’s not getting it. The 2015 service plan took a similar approach to the budget, and 2015 was definitely easier than 2014. The acute hospital sector may have the greatest difficulty with a budget €83m less than they have spent in 2015. There is a lot of language about ‘significant financial challenges’ and ‘financial risk’, which is likely to be prophetic.

None of this was unexpected. HSE had suggested an extra €2 billion in budget, or about €1.4 billion in health service spend this year, which was never going to happen. The Irish budget is still very constrained by our commitments to the EU. These commitments may, or may not, be sensible (see a report from Brookings), but Ireland can do little to change them unilaterally.
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